401k Plan data: AICHI FORGE USA, INC. GROUP BENEFIT PLAN plan

AICHI FORGE USA, INC. GROUP BENEFIT PLAN 401k Plan overview

Plan Name	AICHI FORGE USA, INC. GROUP BENEFIT PLAN
Plan identification number	505

AICHI FORGE USA, INC. GROUP BENEFIT PLAN Benefits

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

401k Sponsoring company profile

AICHI FORGE USA, INC. has sponsored the creation of one or more 401k plans.

Company Name: AICHI FORGE USA, INC.

Employer identification number (EIN): 311545045

NAIC Classification: 332110

Additional information about AICHI FORGE USA, INC.

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 2703596

More information about AICHI FORGE USA, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AICHI FORGE USA, INC. GROUP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2023-01-01 JEFF PORTWOOD 2024-09-13
505 2022-01-01 JEFF PORTWOOD 2023-09-13
505 2021-01-01 MARTIN ESSIG 2022-09-28
505 2020-01-01 MARTIN ESSIG 2021-07-27
505 2019-01-01 MARTIN ESSIG 2020-07-31
505 2018-01-01 MARTIN ESSIG 2019-09-19
505 2017-01-01
505 2016-01-01
505 2015-01-01
505 2014-01-01
505 2013-01-01 PAULETTE KELLY PAULETTE KELLY 2014-07-18
505 2012-01-01 PAULETTE KELLY PAULETTE KELLY 2013-07-23
505 2011-01-01 PAULETTE KELLY PAULETTE KELLY 2012-10-05
505 2010-01-01 PAULETTE KELLY PAULETTE KELLY 2011-07-19
505 2009-01-01 PAULETTE KELLY PAULETTE KELLY 2010-08-18

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
505	2023-01-01	JEFF PORTWOOD	2024-09-13
505	2022-01-01	JEFF PORTWOOD	2023-09-13
505	2021-01-01	MARTIN ESSIG	2022-09-28
505	2020-01-01	MARTIN ESSIG	2021-07-27
505	2019-01-01	MARTIN ESSIG	2020-07-31
505	2018-01-01	MARTIN ESSIG	2019-09-19
505	2017-01-01
505	2016-01-01
505	2015-01-01
505	2014-01-01
505	2013-01-01	PAULETTE KELLY		PAULETTE KELLY	2014-07-18
505	2012-01-01	PAULETTE KELLY		PAULETTE KELLY	2013-07-23
505	2011-01-01	PAULETTE KELLY		PAULETTE KELLY	2012-10-05
505	2010-01-01	PAULETTE KELLY		PAULETTE KELLY	2011-07-19
505	2009-01-01	PAULETTE KELLY		PAULETTE KELLY	2010-08-18

Plan Statistics for AICHI FORGE USA, INC. GROUP BENEFIT PLAN

401k plan membership statisitcs for AICHI FORGE USA, INC. GROUP BENEFIT PLAN

Measure Date Value
2023: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 243
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 262
Total of all active and inactive participants 2023-01-01 262
2022: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 256
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 243
Total of all active and inactive participants 2022-01-01 243
2021: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 293
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 256
Total of all active and inactive participants 2021-01-01 256
2020: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 296
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 293
Total of all active and inactive participants 2020-01-01 293
2019: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 300
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 296
Total of all active and inactive participants 2019-01-01 296
2018: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 304
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 300
Total of all active and inactive participants 2018-01-01 300
2017: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 311
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 304
Total of all active and inactive participants 2017-01-01 304
Total participants 2017-01-01 304
2016: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 260
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 311
Total of all active and inactive participants 2016-01-01 311
Total participants 2016-01-01 311
2015: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 319
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 287
Total of all active and inactive participants 2015-01-01 287
Total participants 2015-01-01 287
2014: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 300
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 319
Total of all active and inactive participants 2014-01-01 319
Total participants 2014-01-01 319
2013: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 257
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 300
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 300
2012: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 192
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 257
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 257
2011: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 195
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 192
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 192
2010: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 192
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 195
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 195
2009: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 239
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 192
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 192

Measure	Date	Value
2023: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	243
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	262
Total of all active and inactive participants	2023-01-01	262
2022: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	256
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	243
Total of all active and inactive participants	2022-01-01	243
2021: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	293
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	256
Total of all active and inactive participants	2021-01-01	256
2020: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	296
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	293
Total of all active and inactive participants	2020-01-01	293
2019: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	300
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	296
Total of all active and inactive participants	2019-01-01	296
2018: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	304
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	300
Total of all active and inactive participants	2018-01-01	300
2017: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	311
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	304
Total of all active and inactive participants	2017-01-01	304
Total participants	2017-01-01	304
2016: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	260
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	311
Total of all active and inactive participants	2016-01-01	311
Total participants	2016-01-01	311
2015: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	319
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	287
Total of all active and inactive participants	2015-01-01	287
Total participants	2015-01-01	287
2014: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	300
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	319
Total of all active and inactive participants	2014-01-01	319
Total participants	2014-01-01	319
2013: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	257
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	300
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	300
2012: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	192
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	257
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	257
2011: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	195
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	192
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	192
2010: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	192
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	195
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	195
2009: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	239
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	192
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	192

Form 5500 Responses for AICHI FORGE USA, INC. GROUP BENEFIT PLAN

2023: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2021: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2020: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2019: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2018: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2017: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2016: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2015: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2014: AICHI FORGE USA, INC. GROUP 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 benefit arrangement – Insurance	Yes
2013: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: AICHI FORGE USA, INC. GROUP BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

KY2105

Policy instance

Insurance contract or identification number	KY2105
Number of Individuals Covered	469
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $43,113
Total amount of fees paid to insurance company	USD $8,657
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E3707098

Policy instance

Insurance contract or identification number	E3707098
Number of Individuals Covered	16
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $4,336
Total amount of fees paid to insurance company	USD $2,202
Other welfare benefits provided	ACC, CANCER, CI, HOSP IN, SUPPLIFE
Welfare Benefit Premiums Paid to Carrier	USD $12,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUC 0AREM

Policy instance

Insurance contract or identification number	GUC 0AREM
Number of Individuals Covered	147
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $18,510
Total amount of fees paid to insurance company	USD $8,696
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	259
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $5,874
Total amount of fees paid to insurance company	USD $2,806
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	262
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $7,530
Total amount of fees paid to insurance company	USD $3,568
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $50,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AREM

Policy instance

Insurance contract or identification number	GVTL0AREM
Number of Individuals Covered	133
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,065
Total amount of fees paid to insurance company	USD $4,630
Other welfare benefits provided	LIFE AND AD&D VOL
Welfare Benefit Premiums Paid to Carrier	USD $53,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E3707080

Policy instance

Insurance contract or identification number	E3707080
Number of Individuals Covered	48
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,827
Total amount of fees paid to insurance company	USD $4,612
Other welfare benefits provided	ACC, CANCER, CI, HOSP IN, SUPPLIFE
Welfare Benefit Premiums Paid to Carrier	USD $22,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	511
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $3,567
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

KY2105

Policy instance

Insurance contract or identification number	KY2105
Number of Individuals Covered	427
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $44,970
Total amount of fees paid to insurance company	USD $196
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $458,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,970
Amount paid for insurance broker fees	196
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	468
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,807
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 $3,807
Insurance broker organization code?	3

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

Policy contract number

GUC 0AREM

Policy instance

Insurance contract or identification number	GUC 0AREM
Number of Individuals Covered	150
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17,547
Total amount of fees paid to insurance company	USD $10,094
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,547
Amount paid for insurance broker fees	10094
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0AREM

Policy instance

Insurance contract or identification number	GVTL0AREM
Number of Individuals Covered	138
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,396
Total amount of fees paid to insurance company	USD $4,575
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $62,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,396
Amount paid for insurance broker fees	4575
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	243
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,266
Total amount of fees paid to insurance company	USD $3,569
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $48,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,266
Amount paid for insurance broker fees	3569
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	243
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,712
Total amount of fees paid to insurance company	USD $3,194
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,712
Amount paid for insurance broker fees	3194
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

E3707098

Policy instance

Insurance contract or identification number	E3707098
Number of Individuals Covered	5
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $67
Other welfare benefits provided	ACC, CANCER, CI, HOSP, SUPP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $2,043
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
Insurance broker organization code?	3

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

Policy contract number

E3707080

Policy instance

Insurance contract or identification number	E3707080
Number of Individuals Covered	7
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $248
Other welfare benefits provided	ACC, CANCER, CI, HOSP, SUPP LIF
Welfare Benefit Premiums Paid to Carrier	USD $6,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $139
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

KY2105

Policy instance

Insurance contract or identification number	KY2105
Number of Individuals Covered	448
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $48,450
Total amount of fees paid to insurance company	USD $220
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $563,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,450
Amount paid for insurance broker fees	220
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	479
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,302
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 $3,302
Insurance broker organization code?	3

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

Policy contract number

GUC 0AREM

Policy instance

Insurance contract or identification number	GUC 0AREM
Number of Individuals Covered	161
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $19,084
Total amount of fees paid to insurance company	USD $10,203
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $127,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,084
Amount paid for insurance broker fees	10203
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0AREM

Policy instance

Insurance contract or identification number	GVTL0AREM
Number of Individuals Covered	145
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,508
Total amount of fees paid to insurance company	USD $4,941
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $56,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,508
Amount paid for insurance broker fees	4941
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	256
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,623
Total amount of fees paid to insurance company	USD $3,462
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $44,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,623
Amount paid for insurance broker fees	3462
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	256
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,041
Total amount of fees paid to insurance company	USD $3,153
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,041
Amount paid for insurance broker fees	3153
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

E3707098

Policy instance

Insurance contract or identification number	E3707098
Number of Individuals Covered	4
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $48
Other welfare benefits provided	ACC, CANCER, CI, HOSP, SUPP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $1,219
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
Insurance broker organization code?	3

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

Policy contract number

E3707080

Policy instance

Insurance contract or identification number	E3707080
Number of Individuals Covered	13
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $315
Other welfare benefits provided	ACC, CANCER, CI, HOSP, SUPP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $8,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $180
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	569
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,677
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 $2,459
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

KY2105

Policy instance

Insurance contract or identification number	KY2105
Number of Individuals Covered	505
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $72,003
Total amount of fees paid to insurance company	USD $343
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,806,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,358
Amount paid for insurance broker fees	343
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GVTL0AREM

Policy instance

Insurance contract or identification number	GVTL0AREM
Number of Individuals Covered	116
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,470
Total amount of fees paid to insurance company	USD $3,942
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $63,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,172
Amount paid for insurance broker fees	3942
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	293
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,560
Total amount of fees paid to insurance company	USD $2,664
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $43,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,169
Amount paid for insurance broker fees	2664
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	294
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,932
Total amount of fees paid to insurance company	USD $2,605
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,955
Amount paid for insurance broker fees	2605
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUC 0AREM

Policy instance

Insurance contract or identification number	GUC 0AREM
Number of Individuals Covered	193
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $19,408
Total amount of fees paid to insurance company	USD $7,870
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $129,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,303
Amount paid for insurance broker fees	7870
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

E3707098

Policy instance

Insurance contract or identification number	E3707098
Number of Individuals Covered	5
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $100
Other welfare benefits provided	ACC, CANCER, CI, HOSP, SUPP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $2,312
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
Insurance broker organization code?	3

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

Policy contract number

E3707080

Policy instance

Insurance contract or identification number	E3707080
Number of Individuals Covered	13
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $373
Total amount of fees paid to insurance company	USD $15
Other welfare benefits provided	ACC, CANCER, CI, HOSP, SUPP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $234
Amount paid for insurance broker fees	4
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GVTL0AREM

Policy instance

Insurance contract or identification number	GVTL0AREM
Number of Individuals Covered	105
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,006
Total amount of fees paid to insurance company	USD $2,935
Other welfare benefits provided	VOLUNTARY LIFE/AD&D
Welfare Benefit Premiums Paid to Carrier	USD $60,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,006
Amount paid for insurance broker fees	2935
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	296
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,084
Total amount of fees paid to insurance company	USD $1,983
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $40,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,084
Amount paid for insurance broker fees	1983
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	296
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,989
Total amount of fees paid to insurance company	USD $1,945
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,989
Amount paid for insurance broker fees	1945
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUC 0AREM

Policy instance

Insurance contract or identification number	GUC 0AREM
Number of Individuals Covered	190
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $17,997
Total amount of fees paid to insurance company	USD $5,981
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,997
Amount paid for insurance broker fees	5981
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

E3707098

Policy instance

Insurance contract or identification number	E3707098
Number of Individuals Covered	4
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $89
Other welfare benefits provided	ACC, CANCER, CI, HOSP, SUPP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $2,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

KY2105

Policy instance

Insurance contract or identification number	KY2105
Number of Individuals Covered	553
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $64,828
Total amount of fees paid to insurance company	USD $173
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,580,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $64,828
Amount paid for insurance broker fees	173
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	610
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,710
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 $4,710
Insurance broker organization code?	3

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

Policy contract number

GUC 0AREM

Policy instance

Insurance contract or identification number	GUC 0AREM
Number of Individuals Covered	201
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,944
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,483
Insurance broker organization code?	3

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	300
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,835
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,357
Insurance broker organization code?	3

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	300
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,949
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $39,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,466
Insurance broker organization code?	3

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

Policy contract number

GVTL0AREM

Policy instance

Insurance contract or identification number	GVTL0AREM
Number of Individuals Covered	104
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,804
Other welfare benefits provided	VOLUNTARY LIFE/AD&D
Welfare Benefit Premiums Paid to Carrier	USD $58,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,044
Insurance broker organization code?	3

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

Policy contract number

743753

Policy instance

Insurance contract or identification number	743753
Number of Individuals Covered	541
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $71,867
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,472,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71,867
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	574
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,852
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 $3,852
Insurance broker organization code?	3

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	596
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,941
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 $3,941
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

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

Policy contract number

743753

Policy instance

Insurance contract or identification number	743753
Number of Individuals Covered	570
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $87,421
Total amount of fees paid to insurance company	USD $7,860
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,400,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87,421
Insurance broker organization code?	3
Amount paid for insurance broker fees	7860
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	J SMITH LANIER & CO

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

Policy contract number

GVTL0AREM

Policy instance

Insurance contract or identification number	GVTL0AREM
Number of Individuals Covered	105
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,936
Total amount of fees paid to insurance company	USD $2,717
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $59,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,936
Amount paid for insurance broker fees	2717
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	304
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,247
Total amount of fees paid to insurance company	USD $1,477
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $34,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,247
Amount paid for insurance broker fees	1477
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	304
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,822
Total amount of fees paid to insurance company	USD $1,635
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,822
Amount paid for insurance broker fees	1635
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GUC 0AREM

Policy instance

Insurance contract or identification number	GUC 0AREM
Number of Individuals Covered	195
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $18,029
Total amount of fees paid to insurance company	USD $5,015
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $120,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,029
Amount paid for insurance broker fees	5015
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	530
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,425
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 $3,425
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

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

Policy contract number

743753

Policy instance

Insurance contract or identification number	743753
Number of Individuals Covered	532
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $79,299
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,081,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $79,299
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & CO.

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

Policy contract number

GVTL0AREM

Policy instance

Insurance contract or identification number	GVTL0AREM
Number of Individuals Covered	106
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,553
Total amount of fees paid to insurance company	USD $1,953
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $57,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,553
Amount paid for insurance broker fees	1953
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	287
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,455
Total amount of fees paid to insurance company	USD $1,078
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $29,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,455
Amount paid for insurance broker fees	1078
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	287
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,918
Total amount of fees paid to insurance company	USD $1,193
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,918
Amount paid for insurance broker fees	1193
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GUC 0AREM

Policy instance

Insurance contract or identification number	GUC 0AREM
Number of Individuals Covered	183
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $15,215
Total amount of fees paid to insurance company	USD $4,086
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,215
Amount paid for insurance broker fees	4086
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GLTD0AREM

Policy instance

Insurance contract or identification number	GLTD0AREM
Number of Individuals Covered	319
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,929
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,929
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GLUG0AREM

Policy instance

Insurance contract or identification number	GLUG0AREM
Number of Individuals Covered	319
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,484
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $29,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,484
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GVTLOAREM

Policy instance

Insurance contract or identification number	GVTLOAREM
Number of Individuals Covered	122
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $8,603
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $57,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,603
Insurance broker organization code?	4
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

GUC0AREM

Policy instance

Insurance contract or identification number	GUC0AREM
Number of Individuals Covered	205
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $15,449
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,449
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & COMPANY

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

Policy contract number

743753

Policy instance

Insurance contract or identification number	743753
Number of Individuals Covered	608
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $129,702
Total amount of fees paid to insurance company	USD $134
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,197,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $129,702
Amount paid for insurance broker fees	134
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & CO.

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0695050

Policy instance

Insurance contract or identification number	0695050
Number of Individuals Covered	603
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,767
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 $3,767
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10150334

Policy instance

Insurance contract or identification number	10150334
Number of Individuals Covered	210
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,365
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 $73,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,365
Insurance broker name	J. SMITH LANIER & CO.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10150333

Policy instance

Insurance contract or identification number	10150333
Number of Individuals Covered	300
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,271
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 $32,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,271
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10150332

Policy instance

Insurance contract or identification number	10150332
Number of Individuals Covered	300
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,975
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 $29,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,975
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

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

Policy contract number

743753

Policy instance

Insurance contract or identification number	743753
Number of Individuals Covered	502
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $109,199
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	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 $2,689,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $109,199
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & COMPANY

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

695050

Policy instance

Insurance contract or identification number	695050
Number of Individuals Covered	577
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,362
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,362
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

695050

Policy instance

Insurance contract or identification number	695050
Number of Individuals Covered	508
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,655
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,655
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

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

Policy contract number

743753

Policy instance

Insurance contract or identification number	743753
Number of Individuals Covered	488
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $88,234
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	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 $88,234
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & COMPANY

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10150334

Policy instance

Insurance contract or identification number	10150334
Number of Individuals Covered	167
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,031
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 $60,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,031
Insurance broker name	J. SMITH LANIER & CO.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10150333

Policy instance

Insurance contract or identification number	10150333
Number of Individuals Covered	257
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,671
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 $26,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,671
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10150332

Policy instance

Insurance contract or identification number	10150332
Number of Individuals Covered	257
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,408
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 $24,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,408
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & CO.

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

706892

Policy instance

Insurance contract or identification number	706892
Number of Individuals Covered	185
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $55,949
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	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

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

K100334

Policy instance

Insurance contract or identification number	K100334
Number of Individuals Covered	192
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,397
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $121,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

706892

Policy instance

Insurance contract or identification number	706892
Number of Individuals Covered	178
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $44,220
Total amount of fees paid to insurance company	USD $59
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,220
Amount paid for insurance broker fees	59
Additional information about fees paid to insurance broker	NON-MONETARY PAID
Insurance broker organization code?	3
Insurance broker name	J. SMITH LANIER & COMPANY

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

K100334

Policy instance

Insurance contract or identification number	K100334
Number of Individuals Covered	195
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,322
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $115,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,322
Insurance broker organization code?	3
Insurance broker name	J SMITH LANIER & CO-WIS LLC

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Company Name:	AICHI FORGE USA, INC.
Employer identification number (EIN):	311545045
NAIC Classification:	332110

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	2703596