EVERBRIDGE BENEFITS PLAN 401k Plan overview

Plan Name	EVERBRIDGE BENEFITS PLAN
Plan identification number	501

EVERBRIDGE BENEFITS 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) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

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

Company Name:	EVERBRIDGE, INC.
Employer identification number (EIN):	262919312
NAIC Classification:	624200

Additional information about EVERBRIDGE, INC.

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	4493096

More information about EVERBRIDGE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EVERBRIDGE BENEFITS PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-05-01
501	2021-05-01
501	2020-05-01
501	2019-05-01
501	2018-05-01
501	2017-05-01
501	2017-04-01
501	2016-04-01
501	2015-04-01	STEPHANIE LUCEY
501	2015-03-01	TRINA WHITE
501	2014-03-01	TRINA WHITE
501	2013-03-01	TRINA WHITE		TRINA WHITE	2014-12-12
501	2012-03-01	TRINA WHITE		TRINA WHITE	2013-12-12

Plan Statistics for EVERBRIDGE BENEFITS PLAN

401k plan membership statisitcs for EVERBRIDGE BENEFITS PLAN

Measure	Date	Value
2022: EVERBRIDGE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	1,021
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	873
Number of retired or separated participants receiving benefits	2022-05-01	13
Number of other retired or separated participants entitled to future benefits	2022-05-01	0
Total of all active and inactive participants	2022-05-01	886
2021: EVERBRIDGE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-05-01	919
Total number of active participants reported on line 7a of the Form 5500	2021-05-01	1,021
Number of retired or separated participants receiving benefits	2021-05-01	0
Number of other retired or separated participants entitled to future benefits	2021-05-01	0
Total of all active and inactive participants	2021-05-01	1,021
2020: EVERBRIDGE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-05-01	773
Total number of active participants reported on line 7a of the Form 5500	2020-05-01	909
Number of retired or separated participants receiving benefits	2020-05-01	0
Number of other retired or separated participants entitled to future benefits	2020-05-01	10
Total of all active and inactive participants	2020-05-01	919
2019: EVERBRIDGE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-05-01	573
Total number of active participants reported on line 7a of the Form 5500	2019-05-01	745
Number of retired or separated participants receiving benefits	2019-05-01	0
Number of other retired or separated participants entitled to future benefits	2019-05-01	22
Total of all active and inactive participants	2019-05-01	767
2018: EVERBRIDGE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-05-01	491
Total number of active participants reported on line 7a of the Form 5500	2018-05-01	570
Number of retired or separated participants receiving benefits	2018-05-01	3
Number of other retired or separated participants entitled to future benefits	2018-05-01	0
Total of all active and inactive participants	2018-05-01	573
2017: EVERBRIDGE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-05-01	327
Total number of active participants reported on line 7a of the Form 5500	2017-05-01	491
Number of retired or separated participants receiving benefits	2017-05-01	0
Number of other retired or separated participants entitled to future benefits	2017-05-01	0
Total of all active and inactive participants	2017-05-01	491
Total participants, beginning-of-year	2017-04-01	335
Total number of active participants reported on line 7a of the Form 5500	2017-04-01	321
Number of retired or separated participants receiving benefits	2017-04-01	6
Number of other retired or separated participants entitled to future benefits	2017-04-01	0
Total of all active and inactive participants	2017-04-01	327
2016: EVERBRIDGE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-04-01	331
Total number of active participants reported on line 7a of the Form 5500	2016-04-01	329
Number of retired or separated participants receiving benefits	2016-04-01	6
Number of other retired or separated participants entitled to future benefits	2016-04-01	0
Total of all active and inactive participants	2016-04-01	335
2015: EVERBRIDGE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-04-01	200
Total number of active participants reported on line 7a of the Form 5500	2015-04-01	329
Number of retired or separated participants receiving benefits	2015-04-01	2
Number of other retired or separated participants entitled to future benefits	2015-04-01	0
Total of all active and inactive participants	2015-04-01	331
Total participants, beginning-of-year	2015-03-01	199
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	197
Number of retired or separated participants receiving benefits	2015-03-01	3
Number of other retired or separated participants entitled to future benefits	2015-03-01	0
Total of all active and inactive participants	2015-03-01	200
2014: EVERBRIDGE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-03-01	137
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	197
Number of retired or separated participants receiving benefits	2014-03-01	2
Number of other retired or separated participants entitled to future benefits	2014-03-01	0
Total of all active and inactive participants	2014-03-01	199
2013: EVERBRIDGE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-03-01	108
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	134
Number of retired or separated participants receiving benefits	2013-03-01	3
Number of other retired or separated participants entitled to future benefits	2013-03-01	0
Total of all active and inactive participants	2013-03-01	137
2012: EVERBRIDGE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-03-01	94
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	107
Number of retired or separated participants receiving benefits	2012-03-01	1
Total of all active and inactive participants	2012-03-01	108

Form 5500 Responses for EVERBRIDGE BENEFITS PLAN

2022: EVERBRIDGE BENEFITS PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	Submission has been amended	No
2022-05-01	This submission is the final filing	No
2022-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-05-01	Plan is a collectively bargained plan	No
2022-05-01	Plan funding arrangement – Insurance	Yes
2022-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-05-01	Plan benefit arrangement – Insurance	Yes
2022-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: EVERBRIDGE BENEFITS PLAN 2021 form 5500 responses
2021-05-01	Type of plan entity	Single employer plan
2021-05-01	Submission has been amended	No
2021-05-01	This submission is the final filing	No
2021-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-05-01	Plan is a collectively bargained plan	No
2021-05-01	Plan funding arrangement – Insurance	Yes
2021-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-05-01	Plan benefit arrangement – Insurance	Yes
2021-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: EVERBRIDGE BENEFITS PLAN 2020 form 5500 responses
2020-05-01	Type of plan entity	Single employer plan
2020-05-01	Submission has been amended	No
2020-05-01	This submission is the final filing	No
2020-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-05-01	Plan is a collectively bargained plan	No
2020-05-01	Plan funding arrangement – Insurance	Yes
2020-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-05-01	Plan benefit arrangement – Insurance	Yes
2020-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: EVERBRIDGE BENEFITS PLAN 2019 form 5500 responses
2019-05-01	Type of plan entity	Single employer plan
2019-05-01	Submission has been amended	No
2019-05-01	This submission is the final filing	No
2019-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-05-01	Plan is a collectively bargained plan	No
2019-05-01	Plan funding arrangement – Insurance	Yes
2019-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-05-01	Plan benefit arrangement – Insurance	Yes
2019-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: EVERBRIDGE BENEFITS PLAN 2018 form 5500 responses
2018-05-01	Type of plan entity	Single employer plan
2018-05-01	Submission has been amended	No
2018-05-01	This submission is the final filing	No
2018-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-05-01	Plan is a collectively bargained plan	No
2018-05-01	Plan funding arrangement – Insurance	Yes
2018-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-05-01	Plan benefit arrangement – Insurance	Yes
2018-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: EVERBRIDGE BENEFITS PLAN 2017 form 5500 responses
2017-05-01	Type of plan entity	Single employer plan
2017-05-01	Plan funding arrangement – Insurance	Yes
2017-05-01	Plan benefit arrangement – Insurance	Yes
2017-04-01	Type of plan entity	Single employer plan
2017-04-01	Submission has been amended	No
2017-04-01	This submission is the final filing	No
2017-04-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2017-04-01	Plan is a collectively bargained plan	No
2017-04-01	Plan funding arrangement – Insurance	Yes
2017-04-01	Plan benefit arrangement – Insurance	Yes
2016: EVERBRIDGE BENEFITS PLAN 2016 form 5500 responses
2016-04-01	Type of plan entity	Single employer plan
2016-04-01	Submission has been amended	No
2016-04-01	This submission is the final filing	No
2016-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-04-01	Plan is a collectively bargained plan	No
2016-04-01	Plan funding arrangement – Insurance	Yes
2016-04-01	Plan benefit arrangement – Insurance	Yes
2015: EVERBRIDGE BENEFITS PLAN 2015 form 5500 responses
2015-04-01	Type of plan entity	Single employer plan
2015-04-01	Submission has been amended	No
2015-04-01	This submission is the final filing	No
2015-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-04-01	Plan is a collectively bargained plan	No
2015-04-01	Plan funding arrangement – Insurance	Yes
2015-04-01	Plan benefit arrangement – Insurance	Yes
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Submission has been amended	No
2015-03-01	This submission is the final filing	No
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-03-01	Plan is a collectively bargained plan	No
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2014: EVERBRIDGE BENEFITS PLAN 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Submission has been amended	No
2014-03-01	This submission is the final filing	No
2014-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-03-01	Plan is a collectively bargained plan	No
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2013: EVERBRIDGE BENEFITS PLAN 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Submission has been amended	No
2013-03-01	This submission is the final filing	No
2013-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-03-01	Plan is a collectively bargained plan	No
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2012: EVERBRIDGE BENEFITS PLAN 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Submission has been amended	No
2012-03-01	This submission is the final filing	No
2012-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-03-01	Plan is a collectively bargained plan	No
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00571627
Policy instance	1
Insurance contract or identification number 00571627 Number of Individuals Covered 873 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $89,684 Total amount of fees paid to insurance company USD $27,041 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT; VOLUNTARY COVERAGES; 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 $901,820 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $89,684 Insurance broker organization code? 3 Amount paid for insurance broker fees 27041 Additional information about fees paid to insurance broker FEES
METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )
Policy contract number	9902398
Policy instance	6
Insurance contract or identification number 9902398 Number of Individuals Covered 143 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $3,713 Total amount of fees paid to insurance company USD $509 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 LEGAL PLAN 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 $37,778 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,713 Amount paid for insurance broker fees 509 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5935646
Policy instance	2
Insurance contract or identification number 5935646 Number of Individuals Covered 1896 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $11,984 Total amount of fees paid to insurance company USD $1,806 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 $118,584 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,984 Insurance broker organization code? 3 Amount paid for insurance broker fees 1806 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number	014615
Policy instance	3
Insurance contract or identification number 014615 Number of Individuals Covered 1692 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $26,161 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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? No Commission paid to Insurance Broker USD $26,161 Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number	4958586
Policy instance	4
Insurance contract or identification number 4958586 Number of Individuals Covered 1565 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $173,507 Total amount of fees paid to insurance company USD $88,822 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 Commission paid to Insurance Broker USD $173,507 Amount paid for insurance broker fees 88822 Additional information about fees paid to insurance broker OTHER COMMISSION AND NON-MONETARY COMPENSATION Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	07648A
Policy instance	5
Insurance contract or identification number 07648A Number of Individuals Covered 1 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $1,244 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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 Other welfare benefits provided MEDICAL BENEFITS ABROAD COVERAGE 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 $12,435 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,244 Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00571627
Policy instance	1
Insurance contract or identification number 00571627 Number of Individuals Covered 1021 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $67,272 Total amount of fees paid to insurance company USD $10,046 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT; VOLUNTARY COVERAGES 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 $690,640 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67,272 Amount paid for insurance broker fees 10046 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number	4958586
Policy instance	4
Insurance contract or identification number 4958586 Number of Individuals Covered 1879 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $175,270 Total amount of fees paid to insurance company USD $93,260 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 Commission paid to Insurance Broker USD $175,270 Amount paid for insurance broker fees 93260 Additional information about fees paid to insurance broker OTHER COMMISSION AND NON-MONETARY COMPENSATION Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	07648A001
Policy instance	5
Insurance contract or identification number 07648A001 Number of Individuals Covered 1 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $1,244 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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 Other welfare benefits provided MEDICAL BENEFITS ABROAD COVERAGE 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 $12,435 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,244 Insurance broker organization code? 3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number	014615
Policy instance	3
Insurance contract or identification number 014615 Number of Individuals Covered 1966 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $27,401 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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? No Commission paid to Insurance Broker USD $27,401 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5935646
Policy instance	2
Insurance contract or identification number 5935646 Number of Individuals Covered 2241 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $11,791 Total amount of fees paid to insurance company USD $1,760 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 $118,663 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,791 Amount paid for insurance broker fees 1760 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )
Policy contract number	9902398
Policy instance	6
Insurance contract or identification number 9902398 Number of Individuals Covered 170 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $4,240 Total amount of fees paid to insurance company USD $654 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 LEGAL PLAN 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 $41,057 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,240 Amount paid for insurance broker fees 654 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	07648A001
Policy instance	5
Insurance contract or identification number 07648A001 Number of Individuals Covered 1 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $1,244 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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 Other welfare benefits provided MEDICAL BENEFITS ABROAD COVERAGE 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 $12,435 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,244 Insurance broker organization code? 3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number	014615
Policy instance	3
Insurance contract or identification number 014615 Number of Individuals Covered 1772 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $25,482 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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? No Commission paid to Insurance Broker USD $25,482 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5935646
Policy instance	2
Insurance contract or identification number 5935646 Number of Individuals Covered 1983 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $10,408 Total amount of fees paid to insurance company USD $1,297 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 $104,811 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,408 Amount paid for insurance broker fees 1297 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00571627
Policy instance	1
Insurance contract or identification number 00571627 Number of Individuals Covered 891 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $46,383 Total amount of fees paid to insurance company USD $9,296 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT; VOLUNTARY COVERAGES 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 $108,831 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $46,383 Amount paid for insurance broker fees 9296 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number	4958586
Policy instance	4
Insurance contract or identification number 4958586 Number of Individuals Covered 1701 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $164,476 Total amount of fees paid to insurance company USD $62,974 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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? Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $164,476 Amount paid for insurance broker fees 62974 Additional information about fees paid to insurance broker OTHER COMMISSION AND NON-MONETARY COMPENSATION Insurance broker organization code? 3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	01-017283-00
Policy instance	1
Insurance contract or identification number 01-017283-00 Number of Individuals Covered 745 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $79,010 Total amount of fees paid to insurance company USD $9,859 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 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 $443,228 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,764 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker N/A Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5985646
Policy instance	2
Insurance contract or identification number 5985646 Number of Individuals Covered 1756 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $8,924 Total amount of fees paid to insurance company USD $1,616 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 $92,431 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,881 Amount paid for insurance broker fees 1610 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number	4958586
Policy instance	4
Insurance contract or identification number 4958586 Number of Individuals Covered 2103 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $143,282 Total amount of fees paid to insurance company USD $56,849 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 Commission paid to Insurance Broker USD $143,282 Amount paid for insurance broker fees 56849 Additional information about fees paid to insurance broker OTHER COMMISSION AND NON-MONETARY COMPENSATION Insurance broker organization code? 3
ANTHEM INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 28207 )
Policy contract number	26919312
Policy instance	5
Insurance contract or identification number 26919312 Number of Individuals Covered 749 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 EMPLOYEE ASSISTANCE PROGRAM 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 $8,793 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	07648A001
Policy instance	6
Insurance contract or identification number 07648A001 Number of Individuals Covered 1 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $1,383 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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 Other welfare benefits provided MEDICAL BENEFITS ABROAD COVERAGE Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,915 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,383 Insurance broker organization code? 3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number	014615
Policy instance	3
Insurance contract or identification number 014615 Number of Individuals Covered 1569 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $16,822 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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? No Commission paid to Insurance Broker USD $16,822 Insurance broker organization code? 3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	0101728300
Policy instance	1
Insurance contract or identification number 0101728300 Number of Individuals Covered 570 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $30,532 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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 Yes Temporary Disability Insurance Welfare Benefit Yes 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 $388,960 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,366 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	135288
Policy instance	2
Insurance contract or identification number 135288 Number of Individuals Covered 101 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $3,764 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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 LEGAL 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 $14,979 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,501 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 4
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	KM05935646
Policy instance	3
Insurance contract or identification number KM05935646 Number of Individuals Covered 1245 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $12,751 Total amount of fees paid to insurance company USD $1,419 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 $81,148 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,284 Insurance broker organization code? 3 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker BROKER BONUS
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	KM05935646
Policy instance	4
Insurance contract or identification number KM05935646 Number of Individuals Covered 0 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $81 Total amount of fees paid to insurance company USD $37 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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? No Commission paid to Insurance Broker USD $81 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number	4958586
Policy instance	5
Insurance contract or identification number 4958586 Number of Individuals Covered 1197 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $128,016 Total amount of fees paid to insurance company USD $22,348 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No 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 Commission paid to Insurance Broker USD $89,232 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number	014615
Policy instance	6
Insurance contract or identification number 014615 Number of Individuals Covered 1196 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $14,642 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? 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 $623,339 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,205 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	0101728300
Policy instance	1
Insurance contract or identification number 0101728300 Number of Individuals Covered 491 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $32,913 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $224,784 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,426 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name INDIGO INSURANCE SERVICES, LLC
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	135288
Policy instance	2
Insurance contract or identification number 135288 Number of Individuals Covered 87 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $3,115 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $13,542 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,590 Amount paid for insurance broker fees 0 Insurance broker organization code? 4 Insurance broker name CHRISTA TOWSLEE AND VARIOUS AGENTS
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	KM05935646
Policy instance	3
Insurance contract or identification number KM05935646 Number of Individuals Covered 1230 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $46,274 Total amount of fees paid to insurance company USD $7,008 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $451,055 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $46,274 Amount paid for insurance broker fees 64 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name MARSH AND MCLENNAN AGENCY
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number	KM05935646
Policy instance	4
Insurance contract or identification number KM05935646 Number of Individuals Covered 80 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $855 Total amount of fees paid to insurance company USD $126 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,054 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $855 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: )
Policy contract number	280392
Policy instance	5
Insurance contract or identification number 280392 Number of Individuals Covered 751 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $28,564 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,180 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,564 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number	4958586
Policy instance	6
Insurance contract or identification number 4958586 Number of Individuals Covered 1013 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $89,115 Total amount of fees paid to insurance company USD $50,958 Health Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $89,115 Amount paid for insurance broker fees 50958 Additional information about fees paid to insurance broker OTHER COMMISSION NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AP2H
Policy instance	5
Insurance contract or identification number GLUG0AP2H Number of Individuals Covered 326 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $2,132 Total amount of fees paid to insurance company USD $647 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 ACCIDENTAL DEATH & 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 $14,216 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,132 Amount paid for insurance broker fees 647 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	135288
Policy instance	6
Insurance contract or identification number 135288 Number of Individuals Covered 32 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $1,331 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 PREPAID LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,099 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $602 Insurance broker organization code? 4 Insurance broker name ROBERT MAVERICK
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AP2H
Policy instance	7
Insurance contract or identification number GLTD0AP2H Number of Individuals Covered 326 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $6,086 Total amount of fees paid to insurance company USD $1,817 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 Yes 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 $40,573 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,086 Amount paid for insurance broker fees 1817 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
Policy contract number	50646000
Policy instance	8
Insurance contract or identification number 50646000 Number of Individuals Covered 246 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $19,869 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 Welfare Benefit Premiums Paid to Carrier USD $767,789 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,869 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	465577
Policy instance	9
Insurance contract or identification number 465577 Number of Individuals Covered 257 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $9,993 Total amount of fees paid to insurance company USD $9,136 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 $283,928 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,993 Amount paid for insurance broker fees 9136 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	W0002595
Policy instance	10
Insurance contract or identification number W0002595 Number of Individuals Covered 139 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $57,011 Total amount of fees paid to insurance company USD $824 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 $1,140,232 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $57,011 Amount paid for insurance broker fees 824 Additional information about fees paid to insurance broker BONUS OVERRIDE ALLOCATION Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0AP2H
Policy instance	4
Insurance contract or identification number GUC0AP2H Number of Individuals Covered 14 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $1,002 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 Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,681 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,002 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )
Policy contract number	46162000
Policy instance	3
Insurance contract or identification number 46162000 Number of Individuals Covered 70 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $6,729 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 Welfare Benefit Premiums Paid to Carrier USD $263,937 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,729 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AP2H
Policy instance	2
Insurance contract or identification number GVTL0AP2H Number of Individuals Covered 104 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $3,638 Total amount of fees paid to insurance company USD $1,135 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 ACCIDENTAL DEATH & 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 $24,250 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,638 Amount paid for insurance broker fees 1135 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0AP2H
Policy instance	1
Insurance contract or identification number GUG0AP2H Number of Individuals Covered 202 Insurance policy start date 2015-04-01 Insurance policy end date 2016-03-31 Total amount of commissions paid to insurance broker USD $4,749 Total amount of fees paid to insurance company USD $1,577 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 Yes 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 $31,657 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,749 Amount paid for insurance broker fees 1577 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0AP2H
Policy instance	1
Insurance contract or identification number GUG0AP2H Number of Individuals Covered 104 Insurance policy start date 2015-03-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $232 Total amount of fees paid to insurance company USD $814 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 Yes 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 $1,549 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $232 Amount paid for insurance broker fees 814 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AP2H
Policy instance	2
Insurance contract or identification number GVTL0AP2H Number of Individuals Covered 77 Insurance policy start date 2015-03-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $240 Total amount of fees paid to insurance company USD $793 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 ACCIDENTAL DEATH & 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 $1,599 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $240 Amount paid for insurance broker fees 793 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
Policy contract number	50646000
Policy instance	3
Insurance contract or identification number 50646000 Number of Individuals Covered 119 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $10,502 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 Welfare Benefit Premiums Paid to Carrier USD $397,601 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,932 Insurance broker organization code? 3 Insurance broker name DEBORAH S BABINEAU
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AP2H
Policy instance	4
Insurance contract or identification number GLUG0AP2H Number of Individuals Covered 197 Insurance policy start date 2015-03-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $121 Total amount of fees paid to insurance company USD $422 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 ACCIDENTAL DEATH & 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 $808 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $121 Amount paid for insurance broker fees 422 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	465577
Policy instance	5
Insurance contract or identification number 465577 Number of Individuals Covered 183 Insurance policy start date 2015-03-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $394 Total amount of fees paid to insurance company USD $6,169 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 $17,350 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $394 Amount paid for insurance broker fees 6169 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	W0002595
Policy instance	6
Insurance contract or identification number W0002595 Number of Individuals Covered 114 Insurance policy start date 2015-03-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $4,557 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 Welfare Benefit Premiums Paid to Carrier USD $91,146 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,557 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	135288
Policy instance	7
Insurance contract or identification number 135288 Number of Individuals Covered 24 Insurance policy start date 2015-03-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $184 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 PREPAID LEGAL 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 $845 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $83 Insurance broker organization code? 4 Insurance broker name ROBERT MAVERICK
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AP2H
Policy instance	8
Insurance contract or identification number GLTD0AP2H Number of Individuals Covered 197 Insurance policy start date 2015-03-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $333 Total amount of fees paid to insurance company USD $1,166 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 Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,217 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $333 Amount paid for insurance broker fees 1166 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0AP2H
Policy instance	9
Insurance contract or identification number GUC0AP2H Number of Individuals Covered 15 Insurance policy start date 2015-03-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $73 Total amount of fees paid to insurance company USD $285 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 Yes 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 $486 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $73 Amount paid for insurance broker fees 285 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )
Policy contract number	46162000
Policy instance	10
Insurance contract or identification number 46162000 Number of Individuals Covered 39 Insurance policy start date 2014-04-01 Insurance policy end date 2015-03-31 Total amount of commissions paid to insurance broker USD $3,565 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 Welfare Benefit Premiums Paid to Carrier USD $131,858 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,163 Insurance broker organization code? 3 Insurance broker name DEBORAH S BABINEAU
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	MJ491
Policy instance	4
Insurance contract or identification number MJ491 Number of Individuals Covered 11 Insurance policy start date 2014-03-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $834 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 $8,865 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $834 Insurance broker organization code? 3 Insurance broker name AFLAC - SEE ATTACHMENT
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AP2H
Policy instance	3
Insurance contract or identification number GLUG0AP2H Number of Individuals Covered 197 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $1,273 Total amount of fees paid to insurance company USD $101 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 ACCIDENTAL DEATH & 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 $8,492 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,273 Insurance broker organization code? 3 Amount paid for insurance broker fees 101 Additional information about fees paid to insurance broker BONUS Insurance broker name BB&H BENEFIT DESIGNS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AP2H
Policy instance	1
Insurance contract or identification number GLTD0AP2H Number of Individuals Covered 197 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $3,486 Total amount of fees paid to insurance company USD $295 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 Yes 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 $23,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,486 Insurance broker organization code? 3 Amount paid for insurance broker fees 295 Additional information about fees paid to insurance broker BONUS Insurance broker name BB&H BENEFIT DESIGNS
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
Policy contract number	50646000
Policy instance	2
Insurance contract or identification number 50646000 Number of Individuals Covered 83 Insurance policy start date 2014-03-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $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 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 $23,646 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $728 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0AP2H
Policy instance	5
Insurance contract or identification number GUG0AP2H Number of Individuals Covered 105 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $2,469 Total amount of fees paid to insurance company USD $179 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 Yes 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 $16,458 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,469 Insurance broker organization code? 3 Amount paid for insurance broker fees 179 Additional information about fees paid to insurance broker BONUS Insurance broker name BB&H BENEFIT DESIGNS
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	135288
Policy instance	6
Insurance contract or identification number 135288 Number of Individuals Covered 24 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $763 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 PREPAID LEGAL 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 $3,349 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $638 Insurance broker organization code? 4 Insurance broker name BARNEY & BARNEY
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	W0002595
Policy instance	7
Insurance contract or identification number W0002595 Number of Individuals Covered 117 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $33,955 Total amount of fees paid to insurance company USD $472 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 $679,107 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,955 Amount paid for insurance broker fees 472 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	465577
Policy instance	8
Insurance contract or identification number 465577 Number of Individuals Covered 180 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $5,454 Total amount of fees paid to insurance company USD $4,268 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 $141,708 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,454 Insurance broker organization code? 3 Amount paid for insurance broker fees 4268 Additional information about fees paid to insurance broker BONUS Insurance broker name BB&H BENEFIT DESIGNS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0AP2H
Policy instance	10
Insurance contract or identification number GUC0AP2H Number of Individuals Covered 15 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $815 Total amount of fees paid to insurance company USD $101 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 Yes 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 $5,437 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $815 Insurance broker organization code? 3 Amount paid for insurance broker fees 101 Additional information about fees paid to insurance broker BONUS Insurance broker name BB&H BENEFIT DESIGNS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AP2H
Policy instance	9
Insurance contract or identification number GVTL0AP2H Number of Individuals Covered 77 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $2,410 Total amount of fees paid to insurance company USD $190 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 ACCIDENTAL DEATH & 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 $16,066 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,410 Insurance broker organization code? 3 Amount paid for insurance broker fees 190 Additional information about fees paid to insurance broker BONUS Insurance broker name BB&H BENEFIT DESIGNS
TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 )
Policy contract number	46162000
Policy instance	11
Insurance contract or identification number 46162000 Number of Individuals Covered 26 Insurance policy start date 2014-03-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $312 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 Welfare Benefit Premiums Paid to Carrier USD $11,602 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $312 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	MJ491
Policy instance	4
Insurance contract or identification number MJ491 Number of Individuals Covered 11 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $1,176 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 $12,504 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $687 Insurance broker organization code? 3 Insurance broker name GEOFFREY MALAIS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0AP2H
Policy instance	2
Insurance contract or identification number GVTL0AP2H Number of Individuals Covered 52 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $1,534 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 ACCIDENTAL DEATH & 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 $10,224 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,249 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0AP2H
Policy instance	1
Insurance contract or identification number GUC0AP2H Number of Individuals Covered 13 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $781 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 Yes 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 $5,204 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $653 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	W0002595/H55686
Policy instance	3
Insurance contract or identification number W0002595/H55686 Number of Individuals Covered 144 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $22,832 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 Welfare Benefit Premiums Paid to Carrier USD $456,644 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,415 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0AP2H
Policy instance	5
Insurance contract or identification number GLTD0AP2H Number of Individuals Covered 134 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $2,613 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 Yes 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 $17,415 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,149 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0AP2H
Policy instance	6
Insurance contract or identification number GLUG0AP2H Number of Individuals Covered 134 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $902 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 ACCIDENTAL DEATH & 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 $6,012 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $740 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
Policy contract number	46162000
Policy instance	7
Insurance contract or identification number 46162000 Number of Individuals Covered 12 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $2,652 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 Welfare Benefit Premiums Paid to Carrier USD $94,710 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,652 Insurance broker organization code? 3 Insurance broker name DEBORAH BABINEAU
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	135288
Policy instance	9
Insurance contract or identification number 135288 Number of Individuals Covered 10 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $438 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 PREPAID LEGAL 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 $1,666 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $438 Insurance broker organization code? 4 Insurance broker name DAVID E. PAPERNO
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUG0AP2H
Policy instance	10
Insurance contract or identification number GUG0AP2H Number of Individuals Covered 69 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $1,832 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 Yes 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 $12,215 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,507 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	465577
Policy instance	11
Insurance contract or identification number 465577 Number of Individuals Covered 110 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $4,394 Total amount of fees paid to insurance company USD $3,279 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 $98,511 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,964 Amount paid for insurance broker fees 3279 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 )
Policy contract number	5064600
Policy instance	8
Insurance contract or identification number 5064600 Number of Individuals Covered 28 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $7,228 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 Welfare Benefit Premiums Paid to Carrier USD $186,558 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,228 Insurance broker organization code? 3 Insurance broker name DEBORAH BABINEAU
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	135288
Policy instance	2
Insurance contract or identification number 135288 Number of Individuals Covered 6 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $22 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 LEGAL SERVICES PLAN MEMBERSHIPS 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 $1,323 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22 Insurance broker organization code? 4 Insurance broker name DAVID PAPERNO
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00465577
Policy instance	3
Insurance contract or identification number 00465577 Number of Individuals Covered 89 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $4,063 Total amount of fees paid to insurance company USD $1,618 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 $73,526 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,931 Amount paid for insurance broker fees 1618 Additional information about fees paid to insurance broker SALES BONUS Insurance broker organization code? 3 Insurance broker name PACIFIC ADVISORS INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number	000010126396
Policy instance	4
Insurance contract or identification number 000010126396 Number of Individuals Covered 107 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $424 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 AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $424 Insurance broker organization code? 3 Insurance broker name BB&H BENEFIT DESIGNS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number	000010126397
Policy instance	5
Insurance contract or identification number 000010126397 Number of Individuals Covered 105 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $1,207 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 Yes 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 $12,072 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,207 Insurance broker organization code? 3 Insurance broker name BB&H BENEFIT DESIGNS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number	40000100011439
Policy instance	7
Insurance contract or identification number 40000100011439 Number of Individuals Covered 25 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $445 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 AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,447 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $445 Insurance broker organization code? 3 Insurance broker name BB&H BENEFIT DESIGNS
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	MJ491
Policy instance	8
Insurance contract or identification number MJ491 Number of Individuals Covered 14 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $1,510 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 $13,909 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $788 Insurance broker organization code? 3 Insurance broker name MICHAEL FISHER
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract number	H55686
Policy instance	1
Insurance contract or identification number H55686 Number of Individuals Covered 92 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $30,046 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 Welfare Benefit Premiums Paid to Carrier USD $596,095 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,046 Insurance broker organization code? 3 Insurance broker name BB&H BENEFIT DESIGNS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	126398
Policy instance	6
Insurance contract or identification number 126398 Number of Individuals Covered 44 Insurance policy start date 2012-03-01 Insurance policy end date 2013-02-28 Total amount of commissions paid to insurance broker USD $578 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 Yes 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 $5,782 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $578 Insurance broker organization code? 3 Insurance broker name BB&H BENEFIT DESIGNS

Potentially related plans

• EVERBRIDGE BENEFITS PLAN [EIN = 810581093]