401k Plan data: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN plan

OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 401k Plan overview

Plan Name	OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN
Plan identification number	520

OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

OLLIE'S BARGAIN OUTLET, INC. has sponsored the creation of one or more 401k plans.

Company Name: OLLIE'S BARGAIN OUTLET, INC.

Employer identification number (EIN): 251589489

NAIC Classification: 452300

Additional information about OLLIE'S BARGAIN OUTLET, INC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2018-09-01

Company Identification Number: 0803088129

Legal Registered Office Address: 6295 ALLENTOWN BLVD STE 1

HARRISBURG
United States of America (USA)
17112

More information about OLLIE'S BARGAIN OUTLET, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
520 2021-07-01 DELORES YINGST 2023-02-02
520 2020-07-01 HOPE LAKIN 2022-02-08
520 2019-07-01 HOPE LAKIN 2021-01-19
520 2018-07-01 KELLY COSTANZA 2020-01-31
520 2017-07-01
520 2016-07-01
520 2015-07-01
520 2014-07-01 DOUGLAS E. WISEHAUPT DOUGLAS E. WISEHAUPT 2016-01-26
520 2013-07-01 DOUGLAS E. WISEHAUPT DOUGLAS E. WISEHAUPT 2015-01-30
520 2012-07-01 DOUGLAS E. WISEHAUPT DOUGLAS E. WISEHAUPT 2013-12-20
520 2011-07-01 DOUGLAS E. WISEHAUPT DOUGLAS E. WISEHAUPT 2012-11-09
520 2011-01-01 DOUG WISEHAUPT DOUG WISEHAUPT 2012-02-02
520 2010-01-01 DOUG WISEHAUPT DOUG WISEHAUPT 2011-07-21
520 2009-01-01 DOUG WISEHAUPT DOUG WISEHAUPT 2010-08-04

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
520	2021-07-01	DELORES YINGST	2023-02-02
520	2020-07-01	HOPE LAKIN	2022-02-08
520	2019-07-01	HOPE LAKIN	2021-01-19
520	2018-07-01	KELLY COSTANZA	2020-01-31
520	2017-07-01
520	2016-07-01
520	2015-07-01
520	2014-07-01	DOUGLAS E. WISEHAUPT		DOUGLAS E. WISEHAUPT	2016-01-26
520	2013-07-01	DOUGLAS E. WISEHAUPT		DOUGLAS E. WISEHAUPT	2015-01-30
520	2012-07-01	DOUGLAS E. WISEHAUPT		DOUGLAS E. WISEHAUPT	2013-12-20
520	2011-07-01	DOUGLAS E. WISEHAUPT		DOUGLAS E. WISEHAUPT	2012-11-09
520	2011-01-01	DOUG WISEHAUPT		DOUG WISEHAUPT	2012-02-02
520	2010-01-01	DOUG WISEHAUPT		DOUG WISEHAUPT	2011-07-21
520	2009-01-01	DOUG WISEHAUPT		DOUG WISEHAUPT	2010-08-04

Plan Statistics for OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN

401k plan membership statisitcs for OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN

Measure Date Value
2021: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 3,656
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 3,912
Number of retired or separated participants receiving benefits 2021-07-01 17
Total of all active and inactive participants 2021-07-01 3,929
2020: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 3,544
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 3,656
Number of retired or separated participants receiving benefits 2020-07-01 10
Total of all active and inactive participants 2020-07-01 3,666
2019: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 3,053
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 3,544
Number of retired or separated participants receiving benefits 2019-07-01 11
Total of all active and inactive participants 2019-07-01 3,555
2018: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 2,658
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 3,053
Number of retired or separated participants receiving benefits 2018-07-01 14
Total of all active and inactive participants 2018-07-01 3,067
2017: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 2,320
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 2,658
Number of retired or separated participants receiving benefits 2017-07-01 27
Total of all active and inactive participants 2017-07-01 2,685
2016: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 2,151
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 2,309
Number of retired or separated participants receiving benefits 2016-07-01 11
Number of other retired or separated participants entitled to future benefits 2016-07-01 0
Total of all active and inactive participants 2016-07-01 2,320
2015: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 1,954
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 2,141
Number of retired or separated participants receiving benefits 2015-07-01 10
Number of other retired or separated participants entitled to future benefits 2015-07-01 0
Total of all active and inactive participants 2015-07-01 2,151
2014: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 1,858
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 1,879
Number of retired or separated participants receiving benefits 2014-07-01 9
Number of other retired or separated participants entitled to future benefits 2014-07-01 66
Total of all active and inactive participants 2014-07-01 1,954
2013: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 1,528
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 1,782
Number of retired or separated participants receiving benefits 2013-07-01 7
Number of other retired or separated participants entitled to future benefits 2013-07-01 69
Total of all active and inactive participants 2013-07-01 1,858
2012: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 1,356
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 1,481
Number of retired or separated participants receiving benefits 2012-07-01 6
Number of other retired or separated participants entitled to future benefits 2012-07-01 41
Total of all active and inactive participants 2012-07-01 1,528
2011: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 1,055
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 1,351
Number of retired or separated participants receiving benefits 2011-07-01 5
Total of all active and inactive participants 2011-07-01 1,356
Total participants, beginning-of-year 2011-01-01 1,088
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,048
Number of retired or separated participants receiving benefits 2011-01-01 7
Total of all active and inactive participants 2011-01-01 1,055
2010: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 942
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 1,079
Number of retired or separated participants receiving benefits 2010-01-01 9
Total of all active and inactive participants 2010-01-01 1,088
2009: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 785
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 935
Number of retired or separated participants receiving benefits 2009-01-01 7
Total of all active and inactive participants 2009-01-01 942

Measure	Date	Value
2021: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	3,656
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	3,912
Number of retired or separated participants receiving benefits	2021-07-01	17
Total of all active and inactive participants	2021-07-01	3,929
2020: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	3,544
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	3,656
Number of retired or separated participants receiving benefits	2020-07-01	10
Total of all active and inactive participants	2020-07-01	3,666
2019: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	3,053
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	3,544
Number of retired or separated participants receiving benefits	2019-07-01	11
Total of all active and inactive participants	2019-07-01	3,555
2018: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	2,658
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	3,053
Number of retired or separated participants receiving benefits	2018-07-01	14
Total of all active and inactive participants	2018-07-01	3,067
2017: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	2,320
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	2,658
Number of retired or separated participants receiving benefits	2017-07-01	27
Total of all active and inactive participants	2017-07-01	2,685
2016: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	2,151
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	2,309
Number of retired or separated participants receiving benefits	2016-07-01	11
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	2,320
2015: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	1,954
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	2,141
Number of retired or separated participants receiving benefits	2015-07-01	10
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	2,151
2014: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	1,858
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	1,879
Number of retired or separated participants receiving benefits	2014-07-01	9
Number of other retired or separated participants entitled to future benefits	2014-07-01	66
Total of all active and inactive participants	2014-07-01	1,954
2013: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	1,528
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	1,782
Number of retired or separated participants receiving benefits	2013-07-01	7
Number of other retired or separated participants entitled to future benefits	2013-07-01	69
Total of all active and inactive participants	2013-07-01	1,858
2012: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	1,356
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	1,481
Number of retired or separated participants receiving benefits	2012-07-01	6
Number of other retired or separated participants entitled to future benefits	2012-07-01	41
Total of all active and inactive participants	2012-07-01	1,528
2011: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	1,055
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	1,351
Number of retired or separated participants receiving benefits	2011-07-01	5
Total of all active and inactive participants	2011-07-01	1,356
Total participants, beginning-of-year	2011-01-01	1,088
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,048
Number of retired or separated participants receiving benefits	2011-01-01	7
Total of all active and inactive participants	2011-01-01	1,055
2010: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	942
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,079
Number of retired or separated participants receiving benefits	2010-01-01	9
Total of all active and inactive participants	2010-01-01	1,088
2009: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	785
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	935
Number of retired or separated participants receiving benefits	2009-01-01	7
Total of all active and inactive participants	2009-01-01	942

Form 5500 Responses for OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN

2021: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: OLLIES BARGAIN OUTLET, INC. FLEXIBLE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	54
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $3,123
Total amount of fees paid to insurance company	USD $232
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,841
Amount paid for insurance broker fees	212
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	2445
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $171,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	1991
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $77,328
Total amount of fees paid to insurance company	USD $13,815
Welfare Benefit Premiums Paid to Carrier	USD $354,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69,586
Amount paid for insurance broker fees	13110
Insurance broker organization code?	3

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

Policy contract number

000405004193 00

Policy instance

Insurance contract or identification number	000405004193 00
Number of Individuals Covered	1004
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $89,458
Total amount of fees paid to insurance company	USD $6,449
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $312,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81,444
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BROKER BONUS

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

Policy contract number

0011098508

Policy instance

Insurance contract or identification number	0011098508
Number of Individuals Covered	1550
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $113,351
Total amount of fees paid to insurance company	USD $17,257
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $404,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $102,411
Amount paid for insurance broker fees	15717
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

24-000030-40

Policy instance

Insurance contract or identification number	24-000030-40
Number of Individuals Covered	619
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $7,637
Total amount of fees paid to insurance company	USD $3,723
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $108,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,637
Amount paid for insurance broker fees	3723
Additional information about fees paid to insurance broker	NY GROUP VOLUME BONUS
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR 227714

Policy instance

Insurance contract or identification number	SR 227714
Number of Individuals Covered	0
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $558
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $558
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

GLTD0BX9L

Policy instance

Insurance contract or identification number	GLTD0BX9L
Number of Individuals Covered	1193
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $30,517
Total amount of fees paid to insurance company	USD $4,375
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $305,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,517
Amount paid for insurance broker fees	4375
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0BX9L

Policy instance

Insurance contract or identification number	GLUG0BX9L
Number of Individuals Covered	3940
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $15,979
Total amount of fees paid to insurance company	USD $2,679
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $159,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,979
Amount paid for insurance broker fees	2679
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUG 0BX9L

Policy instance

Insurance contract or identification number	GUG 0BX9L
Number of Individuals Covered	1193
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $23,622
Total amount of fees paid to insurance company	USD $4,375
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $236,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,622
Amount paid for insurance broker fees	4375
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0BX9L

Policy instance

Insurance contract or identification number	GVTL0BX9L
Number of Individuals Covered	481
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $20,408
Total amount of fees paid to insurance company	USD $2,499
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $136,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,408
Amount paid for insurance broker fees	2499
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	2919
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	1871
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $83,885
Total amount of fees paid to insurance company	USD $13,657
Welfare Benefit Premiums Paid to Carrier	USD $340,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $75,550
Amount paid for insurance broker fees	12903
Insurance broker organization code?	3

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	2578
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $836
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $173,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $836
Insurance broker organization code?	3

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	3054
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000405004193 00

Policy instance

Insurance contract or identification number	000405004193 00
Number of Individuals Covered	1134
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $87,901
Total amount of fees paid to insurance company	USD $7,933
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $297,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $80,257
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BROKER BONUS

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

Policy contract number

0011098508

Policy instance

Insurance contract or identification number	0011098508
Number of Individuals Covered	1570
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $119,725
Total amount of fees paid to insurance company	USD $27,757
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $392,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $108,329
Amount paid for insurance broker fees	26161
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

901390

Policy instance

Insurance contract or identification number	901390
Number of Individuals Covered	3748
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $94,368
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $904,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $94,368
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

24-000030-40

Policy instance

Insurance contract or identification number	24-000030-40
Number of Individuals Covered	603
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $7,194
Total amount of fees paid to insurance company	USD $956
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,194
Amount paid for insurance broker fees	956
Additional information about fees paid to insurance broker	NY GROUP VOLUME BONUS
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	52
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $3,642
Total amount of fees paid to insurance company	USD $300
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,316
Amount paid for insurance broker fees	271
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	1785
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $115,902
Total amount of fees paid to insurance company	USD $20,794
Welfare Benefit Premiums Paid to Carrier	USD $339,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104,586
Amount paid for insurance broker fees	19645
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	2656
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $10,001
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $167,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,001
Insurance broker organization code?	3

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

Policy contract number

901390

Policy instance

Insurance contract or identification number	901390
Number of Individuals Covered	3481
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $93,738
Total amount of fees paid to insurance company	USD $16,744
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $815,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93,738
Amount paid for insurance broker fees	16744
Additional information about fees paid to insurance broker	BONUSES
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

24-000030-40

Policy instance

Insurance contract or identification number	24-000030-40
Number of Individuals Covered	488
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,611
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2611
Additional information about fees paid to insurance broker	NY GROUP VOLUME BONUS
Insurance broker organization code?	3

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

Policy contract number

0011098508

Policy instance

Insurance contract or identification number	0011098508
Number of Individuals Covered	2393
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $132,124
Total amount of fees paid to insurance company	USD $43,891
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $400,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125,287
Amount paid for insurance broker fees	42727
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	120
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $6,177
Total amount of fees paid to insurance company	USD $341
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,020
Amount paid for insurance broker fees	333
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

000405004193 00

Policy instance

Insurance contract or identification number	000405004193 00
Number of Individuals Covered	1147
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $91,194
Total amount of fees paid to insurance company	USD $6,016
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $269,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83,266
Insurance broker organization code?	3
Amount paid for insurance broker fees	6016
Additional information about fees paid to insurance broker	BROKER BONUS

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

Policy contract number

000404003445 00

Policy instance

Insurance contract or identification number	000404003445 00
Number of Individuals Covered	983
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $5,498
Total amount of fees paid to insurance company	USD $3,359
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,987
Insurance broker organization code?	3
Amount paid for insurance broker fees	3359
Additional information about fees paid to insurance broker	BROKER BONUS

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR227714

Policy instance

Insurance contract or identification number	SR227714
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $558
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SPECIAL RISK
Welfare Benefit Premiums Paid to Carrier	USD $3,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $558
Insurance broker organization code?	3

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	3056
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000404003445 00

Policy instance

Insurance contract or identification number	000404003445 00
Number of Individuals Covered	983
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $82,868
Total amount of fees paid to insurance company	USD $19,612
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $246,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76,250
Amount paid for insurance broker fees	19612
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000405004193 00

Policy instance

Insurance contract or identification number	000405004193 00
Number of Individuals Covered	1027
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $76,737
Total amount of fees paid to insurance company	USD $19,059
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $227,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,305
Amount paid for insurance broker fees	19059
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	81
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $8,934
Total amount of fees paid to insurance company	USD $159
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,075
Amount paid for insurance broker fees	131
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0011098508

Policy instance

Insurance contract or identification number	0011098508
Number of Individuals Covered	1502
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $181,399
Total amount of fees paid to insurance company	USD $22,921
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $288,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $167,118
Amount paid for insurance broker fees	21078
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

24-000030-40

Policy instance

Insurance contract or identification number	24-000030-40
Number of Individuals Covered	532
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $2,690
Total amount of fees paid to insurance company	USD $1,139
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,690
Amount paid for insurance broker fees	1139
Additional information about fees paid to insurance broker	NY GROUP VOLUME BONUS
Insurance broker organization code?	3

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

Policy contract number

901390

Policy instance

Insurance contract or identification number	901390
Number of Individuals Covered	3026
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $76,070
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $718,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76,070
Insurance broker organization code?	3

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

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	849
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $60,601
Total amount of fees paid to insurance company	USD $11,563
Welfare Benefit Premiums Paid to Carrier	USD $159,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,834
Amount paid for insurance broker fees	11039
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	2499
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $9,304
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,304
Insurance broker organization code?	3

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	2925
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR227714

Policy instance

Insurance contract or identification number	SR227714
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $279
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SPECIAL RISK
Welfare Benefit Premiums Paid to Carrier	USD $1,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $279
Insurance broker organization code?	3

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

055-4350-00

Policy instance

Insurance contract or identification number	055-4350-00
Number of Individuals Covered	2362
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $12,932
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $100,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12932
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

02870603

Policy instance

Insurance contract or identification number	02870603
Number of Individuals Covered	2146
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $8,564
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $142,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,564
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR227714

Policy instance

Insurance contract or identification number	SR227714
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $279
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SPECIAL RISK
Welfare Benefit Premiums Paid to Carrier	USD $1,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $279
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

000404003445 00

Policy instance

Insurance contract or identification number	000404003445 00
Number of Individuals Covered	770
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $56,617
Total amount of fees paid to insurance company	USD $7,869
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $178,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,600
Amount paid for insurance broker fees	7869
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	489
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $50,580
Total amount of fees paid to insurance company	USD $10,055
Welfare Benefit Premiums Paid to Carrier	USD $91,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,580
Amount paid for insurance broker fees	10055
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	CUSTOM BENEFITS PROG INC

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

Policy contract number

000405004193 00

Policy instance

Insurance contract or identification number	000405004193 00
Number of Individuals Covered	802
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $60,022
Total amount of fees paid to insurance company	USD $9,089
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $180,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $60,016
Amount paid for insurance broker fees	9089
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

R0645671

Policy instance

Insurance contract or identification number	R0645671
Number of Individuals Covered	51
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,310
Total amount of fees paid to insurance company	USD $2
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,310
Amount paid for insurance broker fees	2
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	CUSTOM BENEFITS PROG INC

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

Policy contract number

0011098508

Policy instance

Insurance contract or identification number	0011098508
Number of Individuals Covered	956
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $24,937
Total amount of fees paid to insurance company	USD $8,828
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $226,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,930
Amount paid for insurance broker fees	8828
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

24-000030-40

Policy instance

Insurance contract or identification number	24-000030-40
Number of Individuals Covered	403
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $1,417
Total amount of fees paid to insurance company	USD $393
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,417
Amount paid for insurance broker fees	393
Additional information about fees paid to insurance broker	NY GROUP VOLUME BONUS
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

901390

Policy instance

Insurance contract or identification number	901390
Number of Individuals Covered	2722
Insurance policy start date	2017-09-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $51,409
Total amount of fees paid to insurance company	USD $9,650
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $540,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,409
Amount paid for insurance broker fees	9650
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	2581
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	2120
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
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

THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 )

Policy contract number

G280497

Policy instance

Insurance contract or identification number	G280497
Number of Individuals Covered	360
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

62246

Policy instance

Insurance contract or identification number	62246
Number of Individuals Covered	157
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $8,276
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,558
Insurance broker organization code?	3
Insurance broker name	ROBERT KONZELMAN JR.

ALLSTATE LIFE INSURANCE CO. OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70874 )

Policy contract number

NG442

Policy instance

Insurance contract or identification number	NG442
Number of Individuals Covered	4
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $113
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43
Insurance broker organization code?	3
Insurance broker name	JOHN LUPIANI

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

Policy contract number

02870603

Policy instance

Insurance contract or identification number	02870603
Number of Individuals Covered	1949
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $7,631
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,631
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR227714

Policy instance

Insurance contract or identification number	SR227714
Number of Individuals Covered	0
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $140
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SPECIAL RISK
Welfare Benefit Premiums Paid to Carrier	USD $936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

055-4350-00

Policy instance

Insurance contract or identification number	055-4350-00
Number of Individuals Covered	2242
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $39,009
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $456,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,009
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

62246

Policy instance

Insurance contract or identification number	62246
Number of Individuals Covered	157
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $2,548
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	UNIVERSAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $24,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,536
Insurance broker organization code?	3
Insurance broker name	SHAWN MOSELEY

ALLSTATE LIFE INSURANCE CO. OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70874 )

Policy contract number

0000090581

Policy instance

Insurance contract or identification number	0000090581
Number of Individuals Covered	45
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,925
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $18,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,059
Insurance broker organization code?	3
Insurance broker name	NATIONS ENROLLMENT SYSTEMS LLC

THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 )

Policy contract number

G280497

Policy instance

Insurance contract or identification number	G280497
Number of Individuals Covered	1194
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
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	NY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $28,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR227714

Policy instance

Insurance contract or identification number	SR227714
Number of Individuals Covered	0
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $140
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	SPECIAL RISK
Welfare Benefit Premiums Paid to Carrier	USD $936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

62246

Policy instance

Insurance contract or identification number	62246
Number of Individuals Covered	186
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $10,197
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $97,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,734
Insurance broker organization code?	3
Insurance broker name	KENT HOLLINGER

ALLSTATE LIFE INSURANCE CO. OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70874 )

Policy contract number

0000090581

Policy instance

Insurance contract or identification number	0000090581
Number of Individuals Covered	51
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $3,225
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
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $32,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,774
Insurance broker organization code?	3
Insurance broker name	NATIONS ENROLLMENT SYSTEMS LLC

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	1782
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
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

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

Policy contract number

02870603

Policy instance

Insurance contract or identification number	02870603
Number of Individuals Covered	1782
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $5,040
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,040
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

055-4350-00

Policy instance

Insurance contract or identification number	055-4350-00
Number of Individuals Covered	2045
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $33,255
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $316,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,255
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

ALLSTATE LIFE INSURANCE CO. OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70874 )

Policy contract number

NG442

Policy instance

Insurance contract or identification number	NG442
Number of Individuals Covered	4
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $135
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 $3,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52
Insurance broker organization code?	3
Insurance broker name	JOHN LUPIANI

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR227714

Policy instance

Insurance contract or identification number	SR227714
Number of Individuals Covered	0
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $125
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	SPECIAL RISK
Welfare Benefit Premiums Paid to Carrier	USD $833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

02870603

Policy instance

Insurance contract or identification number	02870603
Number of Individuals Covered	1483
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $4,985
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,985
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

055-4350-00

Policy instance

Insurance contract or identification number	055-4350-00
Number of Individuals Covered	1600
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $27,515
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $247,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,515
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	134
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,342
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEALTHY REWARDS
Welfare Benefit Premiums Paid to Carrier	USD $23,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,342
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 )

Policy contract number

G280497

Policy instance

Insurance contract or identification number	G280497
Number of Individuals Covered	268
Insurance policy start date	2012-07-15
Insurance policy end date	2013-07-14
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	NY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $22,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

62246

Policy instance

Insurance contract or identification number	62246
Number of Individuals Covered	203
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $6,968
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,680
Insurance broker organization code?	3
Insurance broker name	KENT HOLLINGER

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	122
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,986
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 $99,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,986
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

ALLSTATE LIFE INSURANCE CO. OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70874 )

Policy contract number

NG442

Policy instance

Insurance contract or identification number	NG442
Number of Individuals Covered	4
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $160
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61
Insurance broker organization code?	3
Insurance broker name	JOHN LUPIANI

ALLSTATE LIFE INSURANCE CO. OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70874 )

Policy contract number

0000090581

Policy instance

Insurance contract or identification number	0000090581
Number of Individuals Covered	60
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,008
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
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $20,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,104
Insurance broker organization code?	3
Insurance broker name	NATIONS ENROLLMENT SYSTEMS LLC

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	1561
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
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

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR227714

Policy instance

Insurance contract or identification number	SR227714
Number of Individuals Covered	0
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $119
Total amount of fees paid to insurance company	USD $24
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	SPECIAL RISK
Welfare Benefit Premiums Paid to Carrier	USD $791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $119
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

ALLSTATE LIFE INSURANCE CO. OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70874 )

Policy contract number

0000090581

Policy instance

Insurance contract or identification number	0000090581
Number of Individuals Covered	78
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,813
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
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $36,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,097
Insurance broker organization code?	3
Insurance broker name	NATIONS ENROLLMENT SYSTEMS LLC

ALLSTATE LIFE INSURANCE CO. OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70874 )

Policy contract number

NG442

Policy instance

Insurance contract or identification number	NG442
Number of Individuals Covered	10
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $223
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $85
Insurance broker organization code?	3
Insurance broker name	JOHN LUPIANI

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

62246

Policy instance

Insurance contract or identification number	62246
Number of Individuals Covered	264
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $17,904
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $129,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,413
Insurance broker organization code?	3
Insurance broker name	KENT HOLLINGER

THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 70106 )

Policy contract number

G280497

Policy instance

Insurance contract or identification number	G280497
Number of Individuals Covered	268
Insurance policy start date	2011-07-15
Insurance policy end date	2012-07-14
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	NY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $15,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	152
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,210
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEALTHY REWARDS
Welfare Benefit Premiums Paid to Carrier	USD $42,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,210
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	141
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $16,346
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 $163,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,346
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

055-4350-00

Policy instance

Insurance contract or identification number	055-4350-00
Number of Individuals Covered	1500
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $21,886
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $216,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,886
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

02870603

Policy instance

Insurance contract or identification number	02870603
Number of Individuals Covered	1442
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,121
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,653,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,121
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	1350
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
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

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

Policy contract number

843767-XXX

Policy instance

Insurance contract or identification number	843767-XXX
Number of Individuals Covered	1117
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	187
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $3,419
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	174
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $13,313
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 $133,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

055-4350-00

Policy instance

Insurance contract or identification number	055-4350-00
Number of Individuals Covered	1369
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $9,763
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 $180,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	1120
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $3,734
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	1325
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
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 $4,636,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	1102
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
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 $2,155,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	83
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,141
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	940
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,762
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

843767-000

Policy instance

Insurance contract or identification number	843767-000
Number of Individuals Covered	1040
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
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

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

055-4350-00

Policy instance

Insurance contract or identification number	055-4350-00
Number of Individuals Covered	1048
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $6,207
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 $83,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	118
Insurance policy start date	2011-01-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $4,717
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 $47,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

843767-000

Policy instance

Insurance contract or identification number	843767-000
Number of Individuals Covered	1043
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
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

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	74
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,647
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,647
Insurance broker organization code?	3
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
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
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Amount paid for insurance broker fees	12524
Additional information about fees paid to insurance broker	A SPECIAL PRODUCER COMP PROGRAM THAT IS PROVIDED TO A PRODUCER ONCE THEY GET TO A CERTAIN LEVEL OF SALES
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

ST-0100-2050

Policy instance

Insurance contract or identification number	ST-0100-2050
Number of Individuals Covered	120
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $10,414
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 $104,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,414
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	1095
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $52
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 $3,820,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

055-4350-00

Policy instance

Insurance contract or identification number	055-4350-00
Number of Individuals Covered	1079
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,010
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 $152,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,010
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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

Policy contract number

068288

Policy instance

Insurance contract or identification number	068288
Number of Individuals Covered	930
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,260
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,260
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

SR 227714

Policy instance

Insurance contract or identification number	SR 227714
Number of Individuals Covered	43
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $119
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	TRAVEL ACCIDENT INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $119
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES, INC.

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Company Name:	OLLIE'S BARGAIN OUTLET, INC.
Employer identification number (EIN):	251589489
NAIC Classification:	452300

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2018-09-01
Company Identification Number:	0803088129
Legal Registered Office Address:	6295 ALLENTOWN BLVD STE 1 HARRISBURG United States of America (USA) 17112