401k Plan data: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN plan

THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN
Plan identification number	503

THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Prepaid legal Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: SHEAKLEY GROUP, INC.

Employer identification number (EIN): 311176227

NAIC Classification: 541990
NAIC Description: All Other Professional, Scientific, and Technical Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-01-01
503 2021-01-01
503 2020-01-01
503 2019-01-01
503 2018-01-01 SHANNON CASE SHANNON CASE 2019-06-18
503 2017-01-01 SHANNON CASE SHANNON CASE 2018-07-18
503 2016-01-01 SHANNON CASE SHANNON CASE 2017-07-26
503 2015-01-01 HARRY LYDON
503 2014-01-01 ELENI LISTON
503 2013-01-01 ELENI LISTON
503 2012-01-01 ELENI LISTON
503 2011-01-01 ELENI LISTON
503 2009-01-01 ELENI LISTON

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
503	2022-01-01
503	2021-01-01
503	2020-01-01
503	2019-01-01
503	2018-01-01	SHANNON CASE	SHANNON CASE	2019-06-18
503	2017-01-01	SHANNON CASE	SHANNON CASE	2018-07-18
503	2016-01-01	SHANNON CASE	SHANNON CASE	2017-07-26
503	2015-01-01	HARRY LYDON
503	2014-01-01	ELENI LISTON
503	2013-01-01	ELENI LISTON
503	2012-01-01	ELENI LISTON
503	2011-01-01	ELENI LISTON
503	2009-01-01	ELENI LISTON

Plan Statistics for THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN

Measure Date Value
2022: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 195
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 181
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 181
2021: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 254
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 195
Number of retired or separated participants receiving benefits 2021-01-01 4
Number of other retired or separated participants entitled to future benefits 2021-01-01 13
Total of all active and inactive participants 2021-01-01 212
2020: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 254
Number of retired or separated participants receiving benefits 2020-01-01 2
Number of other retired or separated participants entitled to future benefits 2020-01-01 4
Total of all active and inactive participants 2020-01-01 260
2019: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 268
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 269
Number of retired or separated participants receiving benefits 2019-01-01 1
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 270
2018: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 299
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 268
Number of retired or separated participants receiving benefits 2018-01-01 2
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 270
2017: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 278
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 299
Number of retired or separated participants receiving benefits 2017-01-01 1
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 300
2016: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 280
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 278
Number of retired or separated participants receiving benefits 2016-01-01 2
Number of other retired or separated participants entitled to future benefits 2016-01-01 5
Total of all active and inactive participants 2016-01-01 285
2015: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 291
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 280
Number of retired or separated participants receiving benefits 2015-01-01 6
Number of other retired or separated participants entitled to future benefits 2015-01-01 12
Total of all active and inactive participants 2015-01-01 298
2014: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 317
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 283
Number of retired or separated participants receiving benefits 2014-01-01 3
Number of other retired or separated participants entitled to future benefits 2014-01-01 5
Total of all active and inactive participants 2014-01-01 291
2013: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 429
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 291
Number of retired or separated participants receiving benefits 2013-01-01 4
Number of other retired or separated participants entitled to future benefits 2013-01-01 22
Total of all active and inactive participants 2013-01-01 317
2012: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 386
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 396
Number of retired or separated participants receiving benefits 2012-01-01 7
Number of other retired or separated participants entitled to future benefits 2012-01-01 26
Total of all active and inactive participants 2012-01-01 429
2011: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 401
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 373
Number of retired or separated participants receiving benefits 2011-01-01 4
Number of other retired or separated participants entitled to future benefits 2011-01-01 9
Total of all active and inactive participants 2011-01-01 386
2009: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 383
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 410
Number of retired or separated participants receiving benefits 2009-01-01 9
Number of other retired or separated participants entitled to future benefits 2009-01-01 6
Total of all active and inactive participants 2009-01-01 425

Measure	Date	Value
2022: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	195
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	181
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	181
2021: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	254
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	195
Number of retired or separated participants receiving benefits	2021-01-01	4
Number of other retired or separated participants entitled to future benefits	2021-01-01	13
Total of all active and inactive participants	2021-01-01	212
2020: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	254
Number of retired or separated participants receiving benefits	2020-01-01	2
Number of other retired or separated participants entitled to future benefits	2020-01-01	4
Total of all active and inactive participants	2020-01-01	260
2019: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	268
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	269
Number of retired or separated participants receiving benefits	2019-01-01	1
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	270
2018: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	299
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	268
Number of retired or separated participants receiving benefits	2018-01-01	2
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	270
2017: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	278
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	299
Number of retired or separated participants receiving benefits	2017-01-01	1
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	300
2016: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	280
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	278
Number of retired or separated participants receiving benefits	2016-01-01	2
Number of other retired or separated participants entitled to future benefits	2016-01-01	5
Total of all active and inactive participants	2016-01-01	285
2015: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	291
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	280
Number of retired or separated participants receiving benefits	2015-01-01	6
Number of other retired or separated participants entitled to future benefits	2015-01-01	12
Total of all active and inactive participants	2015-01-01	298
2014: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	317
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	283
Number of retired or separated participants receiving benefits	2014-01-01	3
Number of other retired or separated participants entitled to future benefits	2014-01-01	5
Total of all active and inactive participants	2014-01-01	291
2013: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	429
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	291
Number of retired or separated participants receiving benefits	2013-01-01	4
Number of other retired or separated participants entitled to future benefits	2013-01-01	22
Total of all active and inactive participants	2013-01-01	317
2012: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	386
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	396
Number of retired or separated participants receiving benefits	2012-01-01	7
Number of other retired or separated participants entitled to future benefits	2012-01-01	26
Total of all active and inactive participants	2012-01-01	429
2011: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	401
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	373
Number of retired or separated participants receiving benefits	2011-01-01	4
Number of other retired or separated participants entitled to future benefits	2011-01-01	9
Total of all active and inactive participants	2011-01-01	386
2009: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	383
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	410
Number of retired or separated participants receiving benefits	2009-01-01	9
Number of other retired or separated participants entitled to future benefits	2009-01-01	6
Total of all active and inactive participants	2009-01-01	425

Form 5500 Responses for THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN

2022: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: THE SHEAKLEY GROUP, INC. WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

921136

Policy instance

Insurance contract or identification number	921136
Number of Individuals Covered	181
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $40,561
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 & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $255,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,561
Insurance broker organization code?	3

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

Policy contract number

98088741001

Policy instance

Insurance contract or identification number	98088741001
Number of Individuals Covered	322
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,792
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,792
Insurance broker organization code?	3

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

Policy contract number

921136

Policy instance

Insurance contract or identification number	921136
Number of Individuals Covered	209
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $42,219
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 & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $270,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,219
Insurance broker organization code?	3

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

Policy contract number

98088741001

Policy instance

Insurance contract or identification number	98088741001
Number of Individuals Covered	334
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,597
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,573
Insurance broker organization code?	3

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

Policy contract number

98088741001

Policy instance

Insurance contract or identification number	98088741001
Number of Individuals Covered	405
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,393
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,393
Insurance broker organization code?	3

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

Policy contract number

921136

Policy instance

Insurance contract or identification number	921136
Number of Individuals Covered	209
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $42,572
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 & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $279,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,572
Insurance broker organization code?	3

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

Policy contract number

98088741001

Policy instance

Insurance contract or identification number	98088741001
Number of Individuals Covered	459
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,432
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,432
Insurance broker organization code?	3

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1126

Policy instance

Insurance contract or identification number	1126
Number of Individuals Covered	539
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,116
Total amount of fees paid to insurance company	USD $488
Dental Insurance Welfare Benefit	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 $11,116
Amount paid for insurance broker fees	488
Additional information about fees paid to insurance broker	NEW BUSINESS BONUS
Insurance broker organization code?	3

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

Policy contract number

921136

Policy instance

Insurance contract or identification number	921136
Number of Individuals Covered	220
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $49,444
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 & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $269,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,950
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5469936

Policy instance

Insurance contract or identification number	5469936
Number of Individuals Covered	263
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $41,845
Total amount of fees paid to insurance company	USD $7,860
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $266,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,845
Amount paid for insurance broker fees	7860
Insurance broker organization code?	3

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1126

Policy instance

Insurance contract or identification number	1126
Number of Individuals Covered	531
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $12,370
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,370
Insurance broker organization code?	3

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

Policy contract number

98088741001

Policy instance

Insurance contract or identification number	98088741001
Number of Individuals Covered	424
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,655
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,655
Insurance broker organization code?	3

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5469936

Policy instance

Insurance contract or identification number	5469936
Number of Individuals Covered	272
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $49,992
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 & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $261,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,992
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1126

Policy instance

Insurance contract or identification number	1126
Number of Individuals Covered	613
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $14,511
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,511
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOCIATES INC.

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

Policy contract number

98088741001

Policy instance

Insurance contract or identification number	98088741001
Number of Individuals Covered	464
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,221
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,221
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOCIATES & HORAN SECURITIES

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000003813

Policy instance

Insurance contract or identification number	0000003813
Number of Individuals Covered	80
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,600
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $29,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,477
Insurance broker organization code?	3
Insurance broker name	TERESA M ANTHONY

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5469936

Policy instance

Insurance contract or identification number	5469936
Number of Individuals Covered	254
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $37,406
Total amount of fees paid to insurance company	USD $7,412
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $238,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,406
Amount paid for insurance broker fees	7412
Insurance broker name	HORAN ASSOC INC

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1126

Policy instance

Insurance contract or identification number	1126
Number of Individuals Covered	572
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $14,083
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,083
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

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

Policy contract number

9808874

Policy instance

Insurance contract or identification number	9808874
Number of Individuals Covered	419
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,678
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,678
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC & HORAN SECURITIES

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

Policy contract number

25015

Policy instance

Insurance contract or identification number	25015
Number of Individuals Covered	55
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,558
Total amount of fees paid to insurance company	USD $226
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $41,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,150
Amount paid for insurance broker fees	127
Insurance broker organization code?	3
Insurance broker name	TERRY J SILVERS

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000003813

Policy instance

Insurance contract or identification number	0000003813
Number of Individuals Covered	77
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,769
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $25,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,154
Insurance broker organization code?	3
Insurance broker name	TERESA M ANTHONY

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5469936

Policy instance

Insurance contract or identification number	5469936
Number of Individuals Covered	273
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $36,952
Total amount of fees paid to insurance company	USD $14,049
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $232,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,952
Amount paid for insurance broker fees	14049
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1126

Policy instance

Insurance contract or identification number	1126
Number of Individuals Covered	609
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,573
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,573
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

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

Policy contract number

9808874

Policy instance

Insurance contract or identification number	9808874
Number of Individuals Covered	422
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,493
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,493
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

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

Policy contract number

25015

Policy instance

Insurance contract or identification number	25015
Number of Individuals Covered	64
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,422
Total amount of fees paid to insurance company	USD $126
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $42,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,166
Insurance broker organization code?	3
Amount paid for insurance broker fees	78
Insurance broker name	RAYMOND M WYLIE

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

Policy contract number

KM05582073

Policy instance

Insurance contract or identification number	KM05582073
Number of Individuals Covered	859
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $50,852
Total amount of fees paid to insurance company	USD $6,972
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $429,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,852
Amount paid for insurance broker fees	6972
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

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

Policy contract number

25015

Policy instance

Insurance contract or identification number	25015
Number of Individuals Covered	85
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,408
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $51,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,611
Insurance broker organization code?	3
Insurance broker name	KERRY R PICKARD

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12222494-1172

Policy instance

Insurance contract or identification number	12222494-1172
Number of Individuals Covered	5
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $180
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	180
Insurance broker organization code?	3
Insurance broker name	VISION SERVICE PLAN OF ILLINOIS

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

3813

Policy instance

Insurance contract or identification number	3813
Number of Individuals Covered	71
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,909
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $33,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,699
Insurance broker organization code?	3
Insurance broker name	INGER M PENNINGTON

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

Policy contract number

9808874

Policy instance

Insurance contract or identification number	9808874
Number of Individuals Covered	311
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,917
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,917
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 )

Policy contract number

00026816

Policy instance

Insurance contract or identification number	00026816
Number of Individuals Covered	9
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,796
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $97,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,466
Insurance broker organization code?	3
Insurance broker name	MUTUAL MED INSURANCE SERVICES LLC

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

Policy contract number

KM05582073

Policy instance

Insurance contract or identification number	KM05582073
Number of Individuals Covered	1135
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $56,175
Total amount of fees paid to insurance company	USD $10
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $507,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,813
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

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

Policy contract number

SJ672

Policy instance

Insurance contract or identification number	SJ672
Number of Individuals Covered	4
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $473
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $161
Insurance broker organization code?	3
Insurance broker name	JAMES GRETHEL

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00090646

Policy instance

Insurance contract or identification number	00090646
Number of Individuals Covered	51
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $13,574
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $389,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,154
Insurance broker organization code?	3
Insurance broker name	CBISA REACQUISITION CORP

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12222494-1172

Policy instance

Insurance contract or identification number	12222494-1172
Number of Individuals Covered	4
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $180
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	180
Insurance broker organization code?	3
Insurance broker name	VISION SERVICE PLAN OF ILLINOIS

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

00026816

Policy instance

Insurance contract or identification number	00026816
Number of Individuals Covered	11
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

3813 ACC & CRIT

Policy instance

Insurance contract or identification number	3813 ACC & CRIT
Number of Individuals Covered	65
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,504
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $31,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,444
Insurance broker organization code?	3
Insurance broker name	IAN B BRANYON

WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 )

Policy contract number

00026816

Policy instance

Insurance contract or identification number	00026816
Number of Individuals Covered	11
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

25015

Policy instance

Insurance contract or identification number	25015
Number of Individuals Covered	106
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,283
Total amount of fees paid to insurance company	USD $22
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $57,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,385
Insurance broker organization code?	3
Amount paid for insurance broker fees	13
Additional information about fees paid to insurance broker	108
Insurance broker name	CHRIS BIALKA

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

Policy contract number

9808874

Policy instance

Insurance contract or identification number	9808874
Number of Individuals Covered	401
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,677
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,268
Insurance broker organization code?	3
Insurance broker name	HORAN ASSOC INC

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

00026816

Policy instance

Insurance contract or identification number	00026816
Number of Individuals Covered	19
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11,584
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

KM05582073

Policy instance

Insurance contract or identification number	KM05582073
Number of Individuals Covered	1081
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $54,848
Total amount of fees paid to insurance company	USD $750
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $487,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

25015

Policy instance

Insurance contract or identification number	25015
Number of Individuals Covered	73
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,939
Total amount of fees paid to insurance company	USD $431
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $56,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

DM009

Policy instance

Insurance contract or identification number	DM009
Number of Individuals Covered	8
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,837
Total amount of fees paid to insurance company	USD $102
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $10,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SJ672

Policy instance

Insurance contract or identification number	SJ672
Number of Individuals Covered	2
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $222
Total amount of fees paid to insurance company	USD $23
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00090646

Policy instance

Insurance contract or identification number	00090646
Number of Individuals Covered	52
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $14,040
Total amount of fees paid to insurance company	USD $98
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $386,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

3813 ACC & CRIT

Policy instance

Insurance contract or identification number	3813 ACC & CRIT
Number of Individuals Covered	79
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $23,098
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $31,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12222494-1172

Policy instance

Insurance contract or identification number	12222494-1172
Number of Individuals Covered	12
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $180
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9808874

Policy instance

Insurance contract or identification number	9808874
Number of Individuals Covered	335
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,228
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

DM009

Policy instance

Insurance contract or identification number	DM009
Number of Individuals Covered	18
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,129
Total amount of fees paid to insurance company	USD $137
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $10,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $867
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ELIZABETH GASPAROVIC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12222494-1172

Policy instance

Insurance contract or identification number	12222494-1172
Number of Individuals Covered	12
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	VISION SERVICE PLAN OF ILLINOIS

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

Policy contract number

30815-1101

Policy instance

Insurance contract or identification number	30815-1101
Number of Individuals Covered	139
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,366
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,988
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	TOTAL VISION SERVICES

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

Policy contract number

SJ672

Policy instance

Insurance contract or identification number	SJ672
Number of Individuals Covered	3
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $105
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $828
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
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MICHAEL MCCARTHY

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00182422

Policy instance

Insurance contract or identification number	00182422
Number of Individuals Covered	14
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,648
Total amount of fees paid to insurance company	USD $413
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,472
Amount paid for insurance broker fees	413
Insurance broker organization code?	3
Insurance broker name	CBISA REACQUISITION CORP

WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 )

Policy contract number

00026816

Policy instance

Insurance contract or identification number	00026816
Number of Individuals Covered	15
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $14,221
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $169,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,221
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MUTUAL MED INSURANCE SERVICES LLC

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

Policy contract number

KM05582073

Policy instance

Insurance contract or identification number	KM05582073
Number of Individuals Covered	1097
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $51,568
Total amount of fees paid to insurance company	USD $9,401
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $475,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,568
Amount paid for insurance broker fees	9401
Insurance broker organization code?	3
Insurance broker name	DENNIS R. SHIELS & ASSOCIATES, INC.

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

Policy contract number

25015

Policy instance

Insurance contract or identification number	25015
Number of Individuals Covered	116
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $15,033
Total amount of fees paid to insurance company	USD $711
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER INSURANCE, PERSONAL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $89,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,780
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JOHN JOHNSON

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00090646

Policy instance

Insurance contract or identification number	00090646
Number of Individuals Covered	49
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $11,573
Total amount of fees paid to insurance company	USD $660
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $341,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,169
Amount paid for insurance broker fees	660
Insurance broker organization code?	3
Insurance broker name	CBISA REACQUISITION CORP

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Company Name:	SHEAKLEY GROUP, INC.
Employer identification number (EIN):	311176227
NAIC Classification:	541990
NAIC Description:	All Other Professional, Scientific, and Technical Services