ERIE HOMES FOR CHILDREN AND ADULTS, INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ERIE HOMES FOR CHILDREN AND ADULTS LIFE
| Measure | Date | Value |
|---|
| 2022: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-02-01 | 255 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 233 |
| Total of all active and inactive participants | 2022-02-01 | 233 |
| Total participants | 2022-02-01 | 233 |
| 2020: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 248 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 270 |
| Total of all active and inactive participants | 2020-02-01 | 270 |
| Total participants | 2020-02-01 | 270 |
| 2019: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 242 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 248 |
| Number of retired or separated participants receiving benefits | 2019-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-02-01 | 0 |
| Total of all active and inactive participants | 2019-02-01 | 248 |
| Total participants | 2019-02-01 | 248 |
| 2018: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 248 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 22 |
| Number of retired or separated participants receiving benefits | 2018-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-02-01 | 0 |
| Total of all active and inactive participants | 2018-02-01 | 22 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2018-02-01 | 0 |
| Total participants | 2018-02-01 | 22 |
| Number of participants with account balances | 2018-02-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2018-02-01 | 0 |
| 2017: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 248 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 0 |
| Total of all active and inactive participants | 2017-07-01 | 248 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-07-01 | 0 |
| Total participants | 2017-07-01 | 248 |
| Number of participants with account balances | 2017-07-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2017-07-01 | 0 |
| Number of employers contributing to the scheme | 2017-07-01 | 0 |
| Total participants, beginning-of-year | 2017-02-01 | 249 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 241 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Total of all active and inactive participants | 2017-02-01 | 241 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-02-01 | 0 |
| Total participants | 2017-02-01 | 241 |
| Number of participants with account balances | 2017-02-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2017-02-01 | 0 |
| Number of employers contributing to the scheme | 2017-02-01 | 0 |
| 2016: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 249 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 249 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Total of all active and inactive participants | 2016-02-01 | 249 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2016-02-01 | 0 |
| Total participants | 2016-02-01 | 249 |
| Number of participants with account balances | 2016-02-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2016-02-01 | 0 |
| Number of employers contributing to the scheme | 2016-02-01 | 0 |
| 2015: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 245 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 249 |
| Number of retired or separated participants receiving benefits | 2015-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-02-01 | 0 |
| Total of all active and inactive participants | 2015-02-01 | 249 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-02-01 | 0 |
| Total participants | 2015-02-01 | 249 |
| Number of participants with account balances | 2015-02-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2015-02-01 | 0 |
| Number of employers contributing to the scheme | 2015-02-01 | 0 |
| 2014: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-11-01 | 244 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-11-01 | 245 |
| Number of retired or separated participants receiving benefits | 2014-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-11-01 | 0 |
| Total of all active and inactive participants | 2014-11-01 | 245 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-11-01 | 0 |
| Total participants | 2014-11-01 | 245 |
| Number of participants with account balances | 2014-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2014-11-01 | 0 |
| 2013: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-11-01 | 244 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-11-01 | 246 |
| Number of retired or separated participants receiving benefits | 2013-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-11-01 | 0 |
| Total of all active and inactive participants | 2013-11-01 | 246 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-11-01 | 0 |
| Total participants | 2013-11-01 | 246 |
| Number of participants with account balances | 2013-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2013-11-01 | 0 |
| Number of employers contributing to the scheme | 2013-11-01 | 0 |
| 2012: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-11-01 | 219 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 244 |
| Number of retired or separated participants receiving benefits | 2012-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-11-01 | 0 |
| Total of all active and inactive participants | 2012-11-01 | 244 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2012-11-01 | 0 |
| Total participants | 2012-11-01 | 244 |
| Number of participants with account balances | 2012-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2012-11-01 | 0 |
| Number of employers contributing to the scheme | 2012-11-01 | 0 |
| 2011: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-11-01 | 204 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 219 |
| Number of retired or separated participants receiving benefits | 2011-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-11-01 | 0 |
| Total of all active and inactive participants | 2011-11-01 | 219 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2011-11-01 | 0 |
| Total participants | 2011-11-01 | 219 |
| Number of participants with account balances | 2011-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2011-11-01 | 0 |
| Number of employers contributing to the scheme | 2011-11-01 | 0 |
| 2010: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-11-01 | 199 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-11-01 | 204 |
| Number of retired or separated participants receiving benefits | 2010-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-11-01 | 0 |
| Total of all active and inactive participants | 2010-11-01 | 204 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2010-11-01 | 0 |
| Total participants | 2010-11-01 | 204 |
| Number of participants with account balances | 2010-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2010-11-01 | 0 |
| Number of employers contributing to the scheme | 2010-11-01 | 0 |
| 2009: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-11-01 | 184 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-11-01 | 199 |
| Number of retired or separated participants receiving benefits | 2009-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-11-01 | 0 |
| Total of all active and inactive participants | 2009-11-01 | 199 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-11-01 | 0 |
| Total participants | 2009-11-01 | 199 |
| Number of participants with account balances | 2009-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2009-11-01 | 0 |
| Number of employers contributing to the scheme | 2009-11-01 | 0 |
| 2008: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-11-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-11-01 | 184 |
| Number of retired or separated participants receiving benefits | 2008-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-11-01 | 0 |
| Total of all active and inactive participants | 2008-11-01 | 184 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2008-11-01 | 0 |
| Total participants | 2008-11-01 | 184 |
| Number of participants with account balances | 2008-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2008-11-01 | 0 |
| Number of employers contributing to the scheme | 2008-11-01 | 0 |
| 2007: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-11-01 | 175 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-11-01 | 183 |
| Number of retired or separated participants receiving benefits | 2007-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2007-11-01 | 0 |
| Total of all active and inactive participants | 2007-11-01 | 183 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2007-11-01 | 0 |
| Total participants | 2007-11-01 | 183 |
| Number of participants with account balances | 2007-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2007-11-01 | 0 |
| Number of employers contributing to the scheme | 2007-11-01 | 0 |
| 2006: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2006 401k membership |
|---|
| Total participants, beginning-of-year | 2006-11-01 | 171 |
| Total number of active participants reported on line 7a of the Form 5500 | 2006-11-01 | 175 |
| Number of retired or separated participants receiving benefits | 2006-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2006-11-01 | 0 |
| Total of all active and inactive participants | 2006-11-01 | 175 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2006-11-01 | 0 |
| Total participants | 2006-11-01 | 175 |
| Number of participants with account balances | 2006-11-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2006-11-01 | 0 |
| Number of employers contributing to the scheme | 2006-11-01 | 0 |
| 2022: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2022 form 5500 responses |
|---|
| 2022-02-01 | Type of plan entity | Single employer plan |
| 2022-02-01 | Submission has been amended | No |
| 2022-02-01 | This submission is the final filing | No |
| 2022-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-02-01 | Plan is a collectively bargained plan | No |
| 2022-02-01 | Plan funding arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Single employer plan |
| 2020-02-01 | Submission has been amended | No |
| 2020-02-01 | This submission is the final filing | No |
| 2020-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-02-01 | Plan is a collectively bargained plan | No |
| 2020-02-01 | Plan funding arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Single employer plan |
| 2019-02-01 | Submission has been amended | No |
| 2019-02-01 | This submission is the final filing | No |
| 2019-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-02-01 | Plan is a collectively bargained plan | No |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Single employer plan |
| 2018-02-01 | Submission has been amended | No |
| 2018-02-01 | This submission is the final filing | No |
| 2018-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-02-01 | Plan is a collectively bargained plan | No |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Submission has been amended | No |
| 2017-07-01 | This submission is the final filing | No |
| 2017-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-07-01 | Plan is a collectively bargained plan | No |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | Submission has been amended | No |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2014 form 5500 responses |
|---|
| 2014-11-01 | Type of plan entity | Single employer plan |
| 2014-11-01 | Submission has been amended | No |
| 2014-11-01 | This submission is the final filing | No |
| 2014-11-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2014-11-01 | Plan is a collectively bargained plan | No |
| 2014-11-01 | Plan funding arrangement – Insurance | Yes |
| 2014-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2013 form 5500 responses |
|---|
| 2013-11-01 | Type of plan entity | Single employer plan |
| 2013-11-01 | Submission has been amended | No |
| 2013-11-01 | This submission is the final filing | No |
| 2013-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-11-01 | Plan is a collectively bargained plan | No |
| 2013-11-01 | Plan funding arrangement – Insurance | Yes |
| 2013-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2012 form 5500 responses |
|---|
| 2012-11-01 | Type of plan entity | Single employer plan |
| 2012-11-01 | Submission has been amended | No |
| 2012-11-01 | This submission is the final filing | No |
| 2012-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-11-01 | Plan is a collectively bargained plan | No |
| 2012-11-01 | Plan funding arrangement – Insurance | Yes |
| 2012-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2011 form 5500 responses |
|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | Submission has been amended | No |
| 2011-11-01 | This submission is the final filing | No |
| 2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-11-01 | Plan is a collectively bargained plan | No |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2010 form 5500 responses |
|---|
| 2010-11-01 | Type of plan entity | Single employer plan |
| 2010-11-01 | Submission has been amended | No |
| 2010-11-01 | This submission is the final filing | No |
| 2010-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-11-01 | Plan is a collectively bargained plan | No |
| 2010-11-01 | Plan funding arrangement – Insurance | Yes |
| 2010-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2009 form 5500 responses |
|---|
| 2009-11-01 | Type of plan entity | Single employer plan |
| 2009-11-01 | Submission has been amended | No |
| 2009-11-01 | This submission is the final filing | No |
| 2009-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-11-01 | Plan is a collectively bargained plan | No |
| 2009-11-01 | Plan funding arrangement – Insurance | Yes |
| 2009-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2008 form 5500 responses |
|---|
| 2008-11-01 | Type of plan entity | Single employer plan |
| 2008-11-01 | Submission has been amended | No |
| 2008-11-01 | This submission is the final filing | No |
| 2008-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-11-01 | Plan is a collectively bargained plan | No |
| 2008-11-01 | Plan funding arrangement – Insurance | Yes |
| 2008-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2007 form 5500 responses |
|---|
| 2007-11-01 | Type of plan entity | Single employer plan |
| 2007-11-01 | Submission has been amended | No |
| 2007-11-01 | This submission is the final filing | No |
| 2007-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-11-01 | Plan is a collectively bargained plan | No |
| 2007-11-01 | Plan funding arrangement – Insurance | Yes |
| 2007-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2006: ERIE HOMES FOR CHILDREN AND ADULTS LIFE 2006 form 5500 responses |
|---|
| 2006-11-01 | Type of plan entity | Single employer plan |
| 2006-11-01 | Submission has been amended | No |
| 2006-11-01 | This submission is the final filing | No |
| 2006-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2006-11-01 | Plan is a collectively bargained plan | No |
| 2006-11-01 | Plan funding arrangement – Insurance | Yes |
| 2006-11-01 | Plan benefit arrangement – Insurance | Yes |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 157818 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 157818 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $911 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,282 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $911 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 157826 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 157826 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $854 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,759 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $854 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL157818 |
| Policy instance | 2 |
| Insurance contract or identification number | GL157818 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $790 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $790 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL157826 |
| Policy instance | 1 |
| Insurance contract or identification number | GL157826 | | Number of Individuals Covered | 253 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $678 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,163 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $678 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL157826 |
| Policy instance | 2 |
| Insurance contract or identification number | GL157826 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $726 | | Total amount of fees paid to insurance company | USD $79 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,601 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $726 | | Amount paid for insurance broker fees | 79 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL157818 |
| Policy instance | 1 |
| Insurance contract or identification number | GL157818 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $910 | | Total amount of fees paid to insurance company | USD $94 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,273 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $910 | | Amount paid for insurance broker fees | 94 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 157826 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 157826 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $700 | | Total amount of fees paid to insurance company | USD $80 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,366 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $700 | | Amount paid for insurance broker fees | 80 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 157818 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 157818 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $839 | | Total amount of fees paid to insurance company | USD $88 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,623 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $839 | | Amount paid for insurance broker fees | 88 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 157826 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 157826 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $703 | | Total amount of fees paid to insurance company | USD $80 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,387 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $703 | | Amount paid for insurance broker fees | 80 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 | | Insurance broker name | LOESEL-SCHAAF INSURANCE AGENCY |
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| AETNA LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0478017 |
| Policy instance | 1 |
| Insurance contract or identification number | 0478017 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $616 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $616 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 | | Insurance broker name | LOESEL-SCHAAF INSURANCE AGENCY |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0478017 |
| Policy instance | 1 |
| Insurance contract or identification number | 0478017 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $874 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,149 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $174 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 | | Insurance broker name | BERT COMPANY |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX963724 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX963724 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $300 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,503 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $300 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | THE BERT COMPANY |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX963724 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX963724 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $923 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $923 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | THE BERT COMPANY |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX963724 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX963724 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $862 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE | | Commission paid to Insurance Broker | USD $862 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 | | Insurance broker name | THE BERT COMPANY |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX963724 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX963724 | | Number of Individuals Covered | 219 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $780 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,502 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX963724 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX963724 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $722 | | Total amount of fees paid to insurance company | USD $96 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | Yes | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Other information about contract | GROUP INSURANCE |
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