401k Plan data: SCCR, LLC HEALTH AND WELFARE PLAN plan

SCCR, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	SCCR, LLC HEALTH AND WELFARE PLAN
Plan identification number	501

SCCR, LLC HEALTH AND WELFARE 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)
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

SENATOBIA CONVALESCENT CENTER AND REHAB, LLC has sponsored the creation of one or more 401k plans.

Company Name: SENATOBIA CONVALESCENT CENTER AND REHAB, LLC

Employer identification number (EIN): 260451001

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SCCR, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-06-01 TIFFANY PERRY 2022-03-08
501 2020-06-01 TIFFANY PERRY 2022-08-05
501 2019-06-01 TIFFANY PERRY 2020-12-29
501 2018-06-01 ALAN MCCLURG 2020-03-10
501 2017-06-01
501 2016-06-01
501 2016-06-01 ALAN MCCLURG 2020-01-15
501 2015-06-01 ALAN MCCLURG
501 2014-06-01 ALAN MCCLURG
501 2014-06-01 ALAN MCCLURG
501 2013-06-01 ALAN MCCLURG
501 2012-06-01 JIM FREEMAN
501 2011-06-01 JIM FREEMAN
501 2010-06-01 JIM FREEMAN
501 2009-06-01 JIM FREEMAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2020-06-01	TIFFANY PERRY	2022-03-08
501	2020-06-01	TIFFANY PERRY	2022-08-05
501	2019-06-01	TIFFANY PERRY	2020-12-29
501	2018-06-01	ALAN MCCLURG	2020-03-10
501	2017-06-01
501	2016-06-01
501	2016-06-01	ALAN MCCLURG	2020-01-15
501	2015-06-01	ALAN MCCLURG
501	2014-06-01	ALAN MCCLURG
501	2014-06-01	ALAN MCCLURG
501	2013-06-01	ALAN MCCLURG
501	2012-06-01	JIM FREEMAN
501	2011-06-01	JIM FREEMAN
501	2010-06-01	JIM FREEMAN
501	2009-06-01	JIM FREEMAN

Plan Statistics for SCCR, LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for SCCR, LLC HEALTH AND WELFARE PLAN

Measure Date Value
2020: SCCR, LLC HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 111
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 86
Number of retired or separated participants receiving benefits 2020-06-01 0
Number of other retired or separated participants entitled to future benefits 2020-06-01 0
Total of all active and inactive participants 2020-06-01 86
Number of employers contributing to the scheme 2020-06-01 0
2019: SCCR, LLC HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 107
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 111
Number of retired or separated participants receiving benefits 2019-06-01 0
Number of other retired or separated participants entitled to future benefits 2019-06-01 0
Total of all active and inactive participants 2019-06-01 111
Number of employers contributing to the scheme 2019-06-01 0
2018: SCCR, LLC HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 113
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 107
Number of retired or separated participants receiving benefits 2018-06-01 0
Number of other retired or separated participants entitled to future benefits 2018-06-01 0
Total of all active and inactive participants 2018-06-01 107
Number of employers contributing to the scheme 2018-06-01 0
2017: SCCR, LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 118
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 122
Number of retired or separated participants receiving benefits 2017-06-01 0
Number of other retired or separated participants entitled to future benefits 2017-06-01 0
Total of all active and inactive participants 2017-06-01 122
Number of employers contributing to the scheme 2017-06-01 0
2016: SCCR, LLC HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-06-01 115
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 108
Number of retired or separated participants receiving benefits 2016-06-01 0
Number of other retired or separated participants entitled to future benefits 2016-06-01 0
Total of all active and inactive participants 2016-06-01 108
Number of employers contributing to the scheme 2016-06-01 0
2015: SCCR, LLC HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-06-01 98
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 115
Number of retired or separated participants receiving benefits 2015-06-01 0
Number of other retired or separated participants entitled to future benefits 2015-06-01 0
Total of all active and inactive participants 2015-06-01 115
2014: SCCR, LLC HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-06-01 137
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 98
Number of retired or separated participants receiving benefits 2014-06-01 0
Number of other retired or separated participants entitled to future benefits 2014-06-01 0
Total of all active and inactive participants 2014-06-01 98
2013: SCCR, LLC HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-06-01 137
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 113
Number of retired or separated participants receiving benefits 2013-06-01 1
Number of other retired or separated participants entitled to future benefits 2013-06-01 0
Total of all active and inactive participants 2013-06-01 114
2012: SCCR, LLC HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-06-01 154
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 137
Number of retired or separated participants receiving benefits 2012-06-01 0
Number of other retired or separated participants entitled to future benefits 2012-06-01 0
Total of all active and inactive participants 2012-06-01 137
2011: SCCR, LLC HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-06-01 124
Total number of active participants reported on line 7a of the Form 5500 2011-06-01 154
Number of retired or separated participants receiving benefits 2011-06-01 0
Number of other retired or separated participants entitled to future benefits 2011-06-01 0
Total of all active and inactive participants 2011-06-01 154
2010: SCCR, LLC HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-06-01 124
Total number of active participants reported on line 7a of the Form 5500 2010-06-01 111
Number of retired or separated participants receiving benefits 2010-06-01 0
Number of other retired or separated participants entitled to future benefits 2010-06-01 0
Total of all active and inactive participants 2010-06-01 111
2009: SCCR, LLC HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-06-01 100
Total number of active participants reported on line 7a of the Form 5500 2009-06-01 124
Number of retired or separated participants receiving benefits 2009-06-01 0
Number of other retired or separated participants entitled to future benefits 2009-06-01 0
Total of all active and inactive participants 2009-06-01 124

Measure	Date	Value
2020: SCCR, LLC HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	111
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	86
Number of retired or separated participants receiving benefits	2020-06-01	0
Number of other retired or separated participants entitled to future benefits	2020-06-01	0
Total of all active and inactive participants	2020-06-01	86
Number of employers contributing to the scheme	2020-06-01	0
2019: SCCR, LLC HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	107
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	111
Number of retired or separated participants receiving benefits	2019-06-01	0
Number of other retired or separated participants entitled to future benefits	2019-06-01	0
Total of all active and inactive participants	2019-06-01	111
Number of employers contributing to the scheme	2019-06-01	0
2018: SCCR, LLC HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	113
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	107
Number of retired or separated participants receiving benefits	2018-06-01	0
Number of other retired or separated participants entitled to future benefits	2018-06-01	0
Total of all active and inactive participants	2018-06-01	107
Number of employers contributing to the scheme	2018-06-01	0
2017: SCCR, LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	118
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	122
Number of retired or separated participants receiving benefits	2017-06-01	0
Number of other retired or separated participants entitled to future benefits	2017-06-01	0
Total of all active and inactive participants	2017-06-01	122
Number of employers contributing to the scheme	2017-06-01	0
2016: SCCR, LLC HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	115
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	108
Number of retired or separated participants receiving benefits	2016-06-01	0
Number of other retired or separated participants entitled to future benefits	2016-06-01	0
Total of all active and inactive participants	2016-06-01	108
Number of employers contributing to the scheme	2016-06-01	0
2015: SCCR, LLC HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	98
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	115
Number of retired or separated participants receiving benefits	2015-06-01	0
Number of other retired or separated participants entitled to future benefits	2015-06-01	0
Total of all active and inactive participants	2015-06-01	115
2014: SCCR, LLC HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	137
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	98
Number of retired or separated participants receiving benefits	2014-06-01	0
Number of other retired or separated participants entitled to future benefits	2014-06-01	0
Total of all active and inactive participants	2014-06-01	98
2013: SCCR, LLC HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-06-01	137
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	113
Number of retired or separated participants receiving benefits	2013-06-01	1
Number of other retired or separated participants entitled to future benefits	2013-06-01	0
Total of all active and inactive participants	2013-06-01	114
2012: SCCR, LLC HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-06-01	154
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	137
Number of retired or separated participants receiving benefits	2012-06-01	0
Number of other retired or separated participants entitled to future benefits	2012-06-01	0
Total of all active and inactive participants	2012-06-01	137
2011: SCCR, LLC HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-06-01	124
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	154
Number of retired or separated participants receiving benefits	2011-06-01	0
Number of other retired or separated participants entitled to future benefits	2011-06-01	0
Total of all active and inactive participants	2011-06-01	154
2010: SCCR, LLC HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-06-01	124
Total number of active participants reported on line 7a of the Form 5500	2010-06-01	111
Number of retired or separated participants receiving benefits	2010-06-01	0
Number of other retired or separated participants entitled to future benefits	2010-06-01	0
Total of all active and inactive participants	2010-06-01	111
2009: SCCR, LLC HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-06-01	100
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	124
Number of retired or separated participants receiving benefits	2009-06-01	0
Number of other retired or separated participants entitled to future benefits	2009-06-01	0
Total of all active and inactive participants	2009-06-01	124

Form 5500 Responses for SCCR, LLC HEALTH AND WELFARE PLAN

2020: SCCR, LLC HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Submission has been amended	Yes
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2019: SCCR, LLC HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2018: SCCR, LLC HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2017: SCCR, LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2016: SCCR, LLC HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Submission has been amended	No
2016-06-01	This submission is the final filing	No
2016-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-06-01	Plan is a collectively bargained plan	No
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2015: SCCR, LLC HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Submission has been amended	No
2015-06-01	This submission is the final filing	No
2015-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-06-01	Plan is a collectively bargained plan	No
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2014: SCCR, LLC HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Submission has been amended	No
2014-06-01	This submission is the final filing	No
2014-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-06-01	Plan is a collectively bargained plan	No
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2013: SCCR, LLC HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Submission has been amended	No
2013-06-01	This submission is the final filing	No
2013-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-06-01	Plan is a collectively bargained plan	No
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2012: SCCR, LLC HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Submission has been amended	No
2012-06-01	This submission is the final filing	No
2012-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-06-01	Plan is a collectively bargained plan	No
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2011: SCCR, LLC HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	Submission has been amended	No
2011-06-01	This submission is the final filing	No
2011-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-06-01	Plan is a collectively bargained plan	No
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes
2010: SCCR, LLC HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-06-01	Type of plan entity	Single employer plan
2010-06-01	Submission has been amended	No
2010-06-01	This submission is the final filing	No
2010-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-06-01	Plan is a collectively bargained plan	No
2010-06-01	Plan funding arrangement – Insurance	Yes
2010-06-01	Plan benefit arrangement – Insurance	Yes
2009: SCCR, LLC HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	First time form 5500 has been submitted	Yes
2009-06-01	Submission has been amended	No
2009-06-01	This submission is the final filing	No
2009-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-06-01	Plan is a collectively bargained plan	No
2009-06-01	Plan funding arrangement – Insurance	Yes
2009-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	0
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $0
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	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E5378534

Policy instance

Insurance contract or identification number	E5378534
Number of Individuals Covered	52
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $29,641
Total amount of fees paid to insurance company	USD $8,617
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $62,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,016
Amount paid for insurance broker fees	2688
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874516G

Policy instance

Insurance contract or identification number	874516G
Number of Individuals Covered	86
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $3,121
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $27,766
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,274
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS & BLUE SHIELD OF MISSISSIPPI (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318 ET AL

Policy instance

Insurance contract or identification number	39318 ET AL
Number of Individuals Covered	82
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

SCCR617

Policy instance

Insurance contract or identification number	SCCR617
Number of Individuals Covered	58
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $4,244
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,244
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874516G

Policy instance

Insurance contract or identification number	874516G
Number of Individuals Covered	111
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $4,447
Total amount of fees paid to insurance company	USD $97
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $25,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,447
Amount paid for insurance broker fees	97
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318 ET AL

Policy instance

Insurance contract or identification number	39318 ET AL
Number of Individuals Covered	116
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	69
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $8,082
Total amount of fees paid to insurance company	USD $410
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $47,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,200
Amount paid for insurance broker fees	293
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

SCCR617

Policy instance

Insurance contract or identification number	SCCR617
Number of Individuals Covered	80
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $5,147
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,147
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

SCCR617

Policy instance

Insurance contract or identification number	SCCR617
Number of Individuals Covered	83
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $5,042
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,059
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874516G

Policy instance

Insurance contract or identification number	874516G
Number of Individuals Covered	114
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $5,221
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $34,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,099
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

M3032

Policy instance

Insurance contract or identification number	M3032
Number of Individuals Covered	84
Insurance policy start date	2018-06-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $15,893
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $92,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $15,893
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	103
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $12,465
Total amount of fees paid to insurance company	USD $546
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $70,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,479
Amount paid for insurance broker fees	355
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318 ET AL

Policy instance

Insurance contract or identification number	39318 ET AL
Number of Individuals Covered	109
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

PADM1032

Policy instance

Insurance contract or identification number	PADM1032
Number of Individuals Covered	86
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $20,907
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

SCCR617

Policy instance

Insurance contract or identification number	SCCR617
Number of Individuals Covered	92
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $4,933
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318 ET AL

Policy instance

Insurance contract or identification number	39318 ET AL
Number of Individuals Covered	111
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874516G

Policy instance

Insurance contract or identification number	874516G
Number of Individuals Covered	119
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $5,262
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $35,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	112
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $11,041
Total amount of fees paid to insurance company	USD $261
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $63,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874516G

Policy instance

Insurance contract or identification number	874516G
Number of Individuals Covered	126
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $5,462
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $39,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,731
Insurance broker organization code?	3
Insurance broker name	LS AND ASSOCIATES INS. CONSULTANTS

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318 ET AL

Policy instance

Insurance contract or identification number	39318 ET AL
Number of Individuals Covered	96
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30214

Policy instance

Insurance contract or identification number	30214
Number of Individuals Covered	115
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

11152

Policy instance

Insurance contract or identification number	11152
Number of Individuals Covered	115
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

ER00001268

Policy instance

Insurance contract or identification number	ER00001268
Number of Individuals Covered	115
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $1,016
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER INTENSIVE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $468
Insurance broker organization code?	3
Insurance broker name	ADJUSTMENT HOUSE ACCT.

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	116
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $13,650
Total amount of fees paid to insurance company	USD $590
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $78,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,361
Amount paid for insurance broker fees	258
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	D AND V BUTLER, INC AND OTHER AGENT

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	115
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Insurance broker organization code?	3
Insurance broker name

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30214

Policy instance

Insurance contract or identification number	30214
Number of Individuals Covered	87
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $4,202
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $40,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,101
Insurance broker organization code?	3
Insurance broker name	LS AND ASSOCIATES INS. CONSULTANTS

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	118
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $15,489
Total amount of fees paid to insurance company	USD $1,138
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $76,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,513
Amount paid for insurance broker fees	349
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	J. LEE AND ASSOC. AND OTHER AGENTS

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	118
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $13,270
Total amount of fees paid to insurance company	USD $1,078
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $65,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,720
Amount paid for insurance broker fees	323
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	JOHN EARL LEE AND VARIOUS AGENTS

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

ER00001268

Policy instance

Insurance contract or identification number	ER00001268
Number of Individuals Covered	12
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,169
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER INTENSIVE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $537
Insurance broker organization code?	3
Insurance broker name	ADJUSTMENT HOUSE ACCT.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874516G

Policy instance

Insurance contract or identification number	874516G
Number of Individuals Covered	134
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $5,694
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,847
Insurance broker organization code?	3
Insurance broker name	LS AND ASSOCIATES INS. CONSULTANTS

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

11152

Policy instance

Insurance contract or identification number	11152
Number of Individuals Covered	74
Insurance policy start date	2015-03-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $2,620
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,620
Insurance broker organization code?	3
Insurance broker name	LS AND ASSOCIATES INS. CONSULTING

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318 ET AL

Policy instance

Insurance contract or identification number	39318 ET AL
Number of Individuals Covered	103
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

PAI-M-G00151

Policy instance

Insurance contract or identification number	PAI-M-G00151
Number of Individuals Covered	86
Insurance policy start date	2014-06-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $12,573
Total amount of fees paid to insurance company	USD $1,257
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $62,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,601
Insurance broker organization code?	3
Amount paid for insurance broker fees	1257
Additional information about fees paid to insurance broker	UNDERWRITING FEES
Insurance broker name	RESOLUTIONRE

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

ER00001268

Policy instance

Insurance contract or identification number	ER00001268
Number of Individuals Covered	12
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,169
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER INTENSIVE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30214

Policy instance

Insurance contract or identification number	30214
Number of Individuals Covered	87
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $4,202
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $40,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	118
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $13,270
Total amount of fees paid to insurance company	USD $1,078
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $65,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

874516G

Policy instance

Insurance contract or identification number	874516G
Number of Individuals Covered	134
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $5,694
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

11152

Policy instance

Insurance contract or identification number	11152
Number of Individuals Covered	74
Insurance policy start date	2015-03-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $2,620
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12223

Policy instance

Insurance contract or identification number	12223
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30214

Policy instance

Insurance contract or identification number	30214
Number of Individuals Covered	120
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $1,664
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,500
Insurance broker organization code?	3
Insurance broker name	LS AND ASSOCIATES INS. CONSULTANTS

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

Policy contract number

PAI-M-G00151

Policy instance

Insurance contract or identification number	PAI-M-G00151
Number of Individuals Covered	95
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $25,252
Total amount of fees paid to insurance company	USD $2,145
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $134,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,724
Amount paid for insurance broker fees	10
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARK A. BAILEY

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318 ET AL

Policy instance

Insurance contract or identification number	39318 ET AL
Number of Individuals Covered	120
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

ER00001268

Policy instance

Insurance contract or identification number	ER00001268
Number of Individuals Covered	12
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $1,400
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER INTENSIVE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $625
Insurance broker organization code?	3
Insurance broker name	ADJUSTMENT HOUSE ACCT.

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

Policy contract number

394226

Policy instance

Insurance contract or identification number	394226
Number of Individuals Covered	89
Insurance policy start date	2013-01-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $688
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $675
Insurance broker organization code?	3
Insurance broker name	ALLEN FINANCIAL GROUP, PA

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

Policy contract number

10159130

Policy instance

Insurance contract or identification number	10159130
Number of Individuals Covered	123
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,308
Total amount of fees paid to insurance company	USD $668
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $42,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,628
Insurance broker organization code?	3
Amount paid for insurance broker fees	668
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	MARK A. BAILEY

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	123
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $17,514
Total amount of fees paid to insurance company	USD $149
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $68,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,436
Amount paid for insurance broker fees	64
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	DANIEL WHITEHEAD AND VARIOUS AGENTS

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

Policy contract number

10159130

Policy instance

Insurance contract or identification number	10159130
Number of Individuals Covered	122
Insurance policy start date	2014-01-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $2,551
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,551
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES, LLC

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318/50424

Policy instance

Insurance contract or identification number	39318/50424
Number of Individuals Covered	124
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $21,710
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $21,710
Insurance broker organization code?	3
Insurance broker name	LESLIE SMITH

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

Policy contract number

10159130

Policy instance

Insurance contract or identification number	10159130
Number of Individuals Covered	137
Insurance policy start date	2012-06-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,868
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $25,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,934
Insurance broker organization code?	3
Insurance broker name	MARK A. BAILEY

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30214

Policy instance

Insurance contract or identification number	30214
Number of Individuals Covered	81
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $1,942
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $971
Insurance broker organization code?	3
Insurance broker name	MARK A. BAILEY

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

Policy contract number

394226

Policy instance

Insurance contract or identification number	394226
Number of Individuals Covered	84
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,080
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $33,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,039
Insurance broker organization code?	3
Insurance broker name	ALLEN FINANCIAL GROUP, PA

AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )

Policy contract number

14007

Policy instance

Insurance contract or identification number	14007
Number of Individuals Covered	119
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $23,079
Total amount of fees paid to insurance company	USD $682
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $115,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,165
Amount paid for insurance broker fees	341
Additional information about fees paid to insurance broker	FEES AND OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARK A. BAILEY

AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )

Policy contract number

14007

Policy instance

Insurance contract or identification number	14007
Number of Individuals Covered	28
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $22,853
Total amount of fees paid to insurance company	USD $198
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $114,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,069
Amount paid for insurance broker fees	99
Additional information about fees paid to insurance broker	FEES AND OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARK A. BAILEY

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	134
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $13,128
Total amount of fees paid to insurance company	USD $67
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $55,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,068
Amount paid for insurance broker fees	67
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	MISSISSIPPI LIFE AND HEALTH, INC.

AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )

Policy contract number

802C18

Policy instance

Insurance contract or identification number	802C18
Number of Individuals Covered	154
Insurance policy start date	2012-01-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $1,728
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )

Policy contract number

802C18

Policy instance

Insurance contract or identification number	802C18
Number of Individuals Covered	154
Insurance policy start date	2011-06-01
Insurance policy end date	2011-12-01
Total amount of commissions paid to insurance broker	USD $2,404
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )

Policy contract number

14007

Policy instance

Insurance contract or identification number	14007
Number of Individuals Covered	104
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $21,417
Total amount of fees paid to insurance company	USD $1,084
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $107,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )

Policy contract number

14007

Policy instance

Insurance contract or identification number	14007
Number of Individuals Covered	19
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $22,175
Total amount of fees paid to insurance company	USD $352
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $110,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

394226

Policy instance

Insurance contract or identification number	394226
Number of Individuals Covered	95
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,877
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

30214

Policy instance

Insurance contract or identification number	30214
Number of Individuals Covered	84
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $1,792
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318/50424

Policy instance

Insurance contract or identification number	39318/50424
Number of Individuals Covered	130
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $21,581
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	107
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $26,464
Total amount of fees paid to insurance company	USD $158
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $53,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318/50424

Policy instance

Insurance contract or identification number	39318/50424
Number of Individuals Covered	111
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $22,863
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )

Policy contract number

14007

Policy instance

Insurance contract or identification number	14007
Number of Individuals Covered	91
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $10,545
Total amount of fees paid to insurance company	USD $1,294
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $52,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN PUBLIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60801 )

Policy contract number

14007

Policy instance

Insurance contract or identification number	14007
Number of Individuals Covered	33
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $19,247
Total amount of fees paid to insurance company	USD $1,790
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $96,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

394226

Policy instance

Insurance contract or identification number	394226
Number of Individuals Covered	86
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,693
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

212375

Policy instance

Insurance contract or identification number	212375
Number of Individuals Covered	31
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $989
Total amount of fees paid to insurance company	USD $33
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )

Policy contract number

802C18

Policy instance

Insurance contract or identification number	802C18
Number of Individuals Covered	111
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	61
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $4,173
Total amount of fees paid to insurance company	USD $24
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

39318/50424

Policy instance

Insurance contract or identification number	39318/50424
Number of Individuals Covered	124
Insurance policy start date	2009-01-01
Insurance policy end date	2009-12-31
Total amount of commissions paid to insurance broker	USD $22,980
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $22,980
Insurance broker organization code?	3
Insurance broker name	LESLIE SMITH

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

Policy contract number

394226

Policy instance

Insurance contract or identification number	394226
Number of Individuals Covered	87
Insurance policy start date	2009-01-01
Insurance policy end date	2009-12-31
Total amount of commissions paid to insurance broker	USD $1,690
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,676
Insurance broker organization code?	3
Insurance broker name	ALLEN FINANCIAL GROUP, PA

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

Policy contract number

Policy instance

Insurance contract or identification number	00
Number of Individuals Covered	124
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACDCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

212375

Policy instance

Insurance contract or identification number	212375
Number of Individuals Covered	35
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $1,376
Total amount of fees paid to insurance company	USD $463
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $917
Insurance broker organization code?	3
Amount paid for insurance broker fees	459
Additional information about fees paid to insurance broker	MARKETING FEES
Insurance broker name	FRANK DOHERTY

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

Policy contract number

BYV72

Policy instance

Insurance contract or identification number	BYV72
Number of Individuals Covered	4
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $840
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $545
Insurance broker organization code?	3
Insurance broker name	DANIEL MCMECHAN AND VARIOUS AGENTS

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Company Name:	SENATOBIA CONVALESCENT CENTER AND REHAB, LLC
Employer identification number (EIN):	260451001
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities