401k Plan data: KENNON S. SHEA & ASSOCIATES plan

KENNON S. SHEA & ASSOCIATES 401k Plan overview

Plan Name	KENNON S. SHEA & ASSOCIATES
Plan identification number	501

KENNON S. SHEA & ASSOCIATES 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

KENNON S. SHEA & ASSOCIATES has sponsored the creation of one or more 401k plans.

Company Name: KENNON S. SHEA & ASSOCIATES

Employer identification number (EIN): 330685582

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KENNON S. SHEA & ASSOCIATES

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-03-01 MICHELLE COOK MICHELLE COOK 2015-12-10
501 2013-03-01 TRACI HAWKINS
501 2012-03-01 MICHELLE COOK
501 2011-03-01 ROBIN JENSEN
501 2010-03-01 ROBIN JENSEN
501 2009-03-01 ROBIN JENSEN

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2014-03-01	MICHELLE COOK	MICHELLE COOK	2015-12-10
501	2013-03-01	TRACI HAWKINS
501	2012-03-01	MICHELLE COOK
501	2011-03-01	ROBIN JENSEN
501	2010-03-01	ROBIN JENSEN
501	2009-03-01	ROBIN JENSEN

Plan Statistics for KENNON S. SHEA & ASSOCIATES

401k plan membership statisitcs for KENNON S. SHEA & ASSOCIATES

Measure Date Value
2014: KENNON S. SHEA & ASSOCIATES 2014 401k membership
Total participants, beginning-of-year 2014-03-01 460
Total number of active participants reported on line 7a of the Form 5500 2014-03-01 0
Number of retired or separated participants receiving benefits 2014-03-01 0
Number of other retired or separated participants entitled to future benefits 2014-03-01 0
Total of all active and inactive participants 2014-03-01 0
2013: KENNON S. SHEA & ASSOCIATES 2013 401k membership
Total participants, beginning-of-year 2013-03-01 359
Total number of active participants reported on line 7a of the Form 5500 2013-03-01 457
Number of retired or separated participants receiving benefits 2013-03-01 3
Number of other retired or separated participants entitled to future benefits 2013-03-01 0
Total of all active and inactive participants 2013-03-01 460
2012: KENNON S. SHEA & ASSOCIATES 2012 401k membership
Total participants, beginning-of-year 2012-03-01 285
Total number of active participants reported on line 7a of the Form 5500 2012-03-01 352
Number of retired or separated participants receiving benefits 2012-03-01 7
Number of other retired or separated participants entitled to future benefits 2012-03-01 0
Total of all active and inactive participants 2012-03-01 359
2011: KENNON S. SHEA & ASSOCIATES 2011 401k membership
Total participants, beginning-of-year 2011-03-01 282
Total number of active participants reported on line 7a of the Form 5500 2011-03-01 275
Number of retired or separated participants receiving benefits 2011-03-01 10
Number of other retired or separated participants entitled to future benefits 2011-03-01 0
Total of all active and inactive participants 2011-03-01 285
2010: KENNON S. SHEA & ASSOCIATES 2010 401k membership
Total participants, beginning-of-year 2010-03-01 282
Total number of active participants reported on line 7a of the Form 5500 2010-03-01 282
Number of retired or separated participants receiving benefits 2010-03-01 0
Number of other retired or separated participants entitled to future benefits 2010-03-01 0
Total of all active and inactive participants 2010-03-01 282
2009: KENNON S. SHEA & ASSOCIATES 2009 401k membership
Total participants, beginning-of-year 2009-03-01 299
Total number of active participants reported on line 7a of the Form 5500 2009-03-01 299
Number of retired or separated participants receiving benefits 2009-03-01 0
Number of other retired or separated participants entitled to future benefits 2009-03-01 0
Total of all active and inactive participants 2009-03-01 299

Measure	Date	Value
2014: KENNON S. SHEA & ASSOCIATES 2014 401k membership
Total participants, beginning-of-year	2014-03-01	460
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	0
Number of retired or separated participants receiving benefits	2014-03-01	0
Number of other retired or separated participants entitled to future benefits	2014-03-01	0
Total of all active and inactive participants	2014-03-01	0
2013: KENNON S. SHEA & ASSOCIATES 2013 401k membership
Total participants, beginning-of-year	2013-03-01	359
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	457
Number of retired or separated participants receiving benefits	2013-03-01	3
Number of other retired or separated participants entitled to future benefits	2013-03-01	0
Total of all active and inactive participants	2013-03-01	460
2012: KENNON S. SHEA & ASSOCIATES 2012 401k membership
Total participants, beginning-of-year	2012-03-01	285
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	352
Number of retired or separated participants receiving benefits	2012-03-01	7
Number of other retired or separated participants entitled to future benefits	2012-03-01	0
Total of all active and inactive participants	2012-03-01	359
2011: KENNON S. SHEA & ASSOCIATES 2011 401k membership
Total participants, beginning-of-year	2011-03-01	282
Total number of active participants reported on line 7a of the Form 5500	2011-03-01	275
Number of retired or separated participants receiving benefits	2011-03-01	10
Number of other retired or separated participants entitled to future benefits	2011-03-01	0
Total of all active and inactive participants	2011-03-01	285
2010: KENNON S. SHEA & ASSOCIATES 2010 401k membership
Total participants, beginning-of-year	2010-03-01	282
Total number of active participants reported on line 7a of the Form 5500	2010-03-01	282
Number of retired or separated participants receiving benefits	2010-03-01	0
Number of other retired or separated participants entitled to future benefits	2010-03-01	0
Total of all active and inactive participants	2010-03-01	282
2009: KENNON S. SHEA & ASSOCIATES 2009 401k membership
Total participants, beginning-of-year	2009-03-01	299
Total number of active participants reported on line 7a of the Form 5500	2009-03-01	299
Number of retired or separated participants receiving benefits	2009-03-01	0
Number of other retired or separated participants entitled to future benefits	2009-03-01	0
Total of all active and inactive participants	2009-03-01	299

Form 5500 Responses for KENNON S. SHEA & ASSOCIATES

2014: KENNON S. SHEA & ASSOCIATES 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Submission has been amended	No
2014-03-01	This submission is the final filing	Yes
2014-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-03-01	Plan is a collectively bargained plan	No
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2013: KENNON S. SHEA & ASSOCIATES 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Submission has been amended	No
2013-03-01	This submission is the final filing	No
2013-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-03-01	Plan is a collectively bargained plan	No
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2012: KENNON S. SHEA & ASSOCIATES 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Submission has been amended	No
2012-03-01	This submission is the final filing	No
2012-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-03-01	Plan is a collectively bargained plan	No
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2011: KENNON S. SHEA & ASSOCIATES 2011 form 5500 responses
2011-03-01	Type of plan entity	Single employer plan
2011-03-01	Submission has been amended	No
2011-03-01	This submission is the final filing	No
2011-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-03-01	Plan is a collectively bargained plan	No
2011-03-01	Plan funding arrangement – Insurance	Yes
2011-03-01	Plan benefit arrangement – Insurance	Yes
2010: KENNON S. SHEA & ASSOCIATES 2010 form 5500 responses
2010-03-01	Type of plan entity	Single employer plan
2010-03-01	Submission has been amended	No
2010-03-01	This submission is the final filing	No
2010-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-03-01	Plan is a collectively bargained plan	No
2010-03-01	Plan funding arrangement – Insurance	Yes
2010-03-01	Plan benefit arrangement – Insurance	Yes
2009: KENNON S. SHEA & ASSOCIATES 2009 form 5500 responses
2009-03-01	Type of plan entity	Single employer plan
2009-03-01	First time form 5500 has been submitted	Yes
2009-03-01	Submission has been amended	No
2009-03-01	This submission is the final filing	No
2009-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-03-01	Plan is a collectively bargained plan	No
2009-03-01	Plan funding arrangement – Insurance	Yes
2009-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

EXH61

Policy instance

Insurance contract or identification number	EXH61
Number of Individuals Covered	21
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $2,371
Total amount of fees paid to insurance company	USD $236
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,371
Amount paid for insurance broker fees	236
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

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

Policy contract number

097969 0001

Policy instance

Insurance contract or identification number	097969 0001
Number of Individuals Covered	10
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $1,120
Total amount of fees paid to insurance company	USD $112
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,120
Amount paid for insurance broker fees	112
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

DNA29

Policy instance

Insurance contract or identification number	DNA29
Number of Individuals Covered	9
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $2,036
Total amount of fees paid to insurance company	USD $388
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,036
Amount paid for insurance broker fees	388
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

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

Policy contract number

EL432

Policy instance

Insurance contract or identification number	EL432
Number of Individuals Covered	8
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $940
Total amount of fees paid to insurance company	USD $28
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $940
Amount paid for insurance broker fees	28
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

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

Policy contract number

445894

Policy instance

Insurance contract or identification number	445894
Number of Individuals Covered	16
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $19,215
Total amount of fees paid to insurance company	USD $9,280
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D AND EAP
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 $161,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,215
Amount paid for insurance broker fees	9280
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

456040

Policy instance

Insurance contract or identification number	456040
Number of Individuals Covered	300
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $48,721
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,218,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,721
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

GBZ35

Policy instance

Insurance contract or identification number	GBZ35
Number of Individuals Covered	3
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $1,443
Total amount of fees paid to insurance company	USD $55
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,443
Amount paid for insurance broker fees	55
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

STERLING LIFE (National Association of Insurance Commissioners NAIC id number: 77399 )

Policy contract number

T5345

Policy instance

Insurance contract or identification number	T5345
Number of Individuals Covered	11
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $5,118
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $128,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,118
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

ECL63

Policy instance

Insurance contract or identification number	ECL63
Number of Individuals Covered	23
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $3,273
Total amount of fees paid to insurance company	USD $157
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,273
Amount paid for insurance broker fees	157
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

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

Policy contract number

ESN91

Policy instance

Insurance contract or identification number	ESN91
Number of Individuals Covered	11
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $1,343
Total amount of fees paid to insurance company	USD $19
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,343
Amount paid for insurance broker fees	19
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

414/416/417/418

Policy instance

Insurance contract or identification number	414/416/417/418
Number of Individuals Covered	0
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $5,355
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 $76,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,355
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

EUU77

Policy instance

Insurance contract or identification number	EUU77
Number of Individuals Covered	16
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $2,065
Total amount of fees paid to insurance company	USD $40
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,065
Amount paid for insurance broker fees	40
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

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

Policy contract number

EHF66

Policy instance

Insurance contract or identification number	EHF66
Number of Individuals Covered	0
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $1,383
Total amount of fees paid to insurance company	USD $268
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,383
Amount paid for insurance broker fees	268
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

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

Policy contract number

EFQ18

Policy instance

Insurance contract or identification number	EFQ18
Number of Individuals Covered	19
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $2,313
Total amount of fees paid to insurance company	USD $25
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,313
Amount paid for insurance broker fees	25
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	AFLAC - SEE ATTACHMENT

STERLING LIFE (National Association of Insurance Commissioners NAIC id number: 77399 )

Policy contract number

T5345

Policy instance

Insurance contract or identification number	T5345
Number of Individuals Covered	11
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $5,889
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $147,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,889
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

EFQ18

Policy instance

Insurance contract or identification number	EFQ18
Number of Individuals Covered	19
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $1,537
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $657
Insurance broker organization code?	3
Insurance broker name	MARK HALIM HABER

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

Policy contract number

EHF66

Policy instance

Insurance contract or identification number	EHF66
Number of Individuals Covered	25
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $2,595
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $902
Insurance broker organization code?	3
Insurance broker name	ALFRED RIETKERK

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

Policy contract number

EXH61

Policy instance

Insurance contract or identification number	EXH61
Number of Individuals Covered	25
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $3,612
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,426
Insurance broker organization code?	3
Insurance broker name	BRUCE B BETZ II

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

Policy contract number

097969 0001

Policy instance

Insurance contract or identification number	097969 0001
Number of Individuals Covered	11
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $1,719
Total amount of fees paid to insurance company	USD $205
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,719
Amount paid for insurance broker fees	205
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

414/416/417/418

Policy instance

Insurance contract or identification number	414/416/417/418
Number of Individuals Covered	21
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $2,628
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 $37,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,628
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

ESN91

Policy instance

Insurance contract or identification number	ESN91
Number of Individuals Covered	13
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $853
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $348
Insurance broker organization code?	3
Insurance broker name	ANDREW R GRETHEL

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

456040

Policy instance

Insurance contract or identification number	456040
Number of Individuals Covered	300
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $48,523
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,213,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,523
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

ECL63

Policy instance

Insurance contract or identification number	ECL63
Number of Individuals Covered	25
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $7,097
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $39,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,040
Insurance broker organization code?	3
Insurance broker name	ANDREW R GRETHEL

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

Policy contract number

445894

Policy instance

Insurance contract or identification number	445894
Number of Individuals Covered	353
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $15,036
Total amount of fees paid to insurance company	USD $7,535
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D AND EAP
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 $203,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,036
Amount paid for insurance broker fees	7535
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

DNA29

Policy instance

Insurance contract or identification number	DNA29
Number of Individuals Covered	9
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $4,254
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL BENEFITS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,687
Insurance broker organization code?	3
Insurance broker name	ANDREW R GRETHEL

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

Policy contract number

445894

Policy instance

Insurance contract or identification number	445894
Number of Individuals Covered	308
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $13,215
Total amount of fees paid to insurance company	USD $1,892
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $223,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,215
Amount paid for insurance broker fees	1892
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

SD9233/S21457

Policy instance

Insurance contract or identification number	SD9233/S21457
Number of Individuals Covered	35
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $19,161
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $273,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,161
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

125937

Policy instance

Insurance contract or identification number	125937
Number of Individuals Covered	12
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $3,703
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $96,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,703
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 )

Policy contract number

1001

Policy instance

Insurance contract or identification number	1001
Number of Individuals Covered	675
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

15240

Policy instance

Insurance contract or identification number	15240
Number of Individuals Covered	281
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $51,474
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,286,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,474
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

414

Policy instance

Insurance contract or identification number	414
Number of Individuals Covered	1
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $174
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 $2,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $174
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

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

Policy contract number

445894

Policy instance

Insurance contract or identification number	445894
Number of Individuals Covered	301
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $6,574
Total amount of fees paid to insurance company	USD $2,914
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $140,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

125937

Policy instance

Insurance contract or identification number	125937
Number of Individuals Covered	16
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $7,212
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $181,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

SD9233/S21457

Policy instance

Insurance contract or identification number	SD9233/S21457
Number of Individuals Covered	25
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $12,815
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $183,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

15240

Policy instance

Insurance contract or identification number	15240
Number of Individuals Covered	301
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $47,335
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,183,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00445894

Policy instance

Insurance contract or identification number	00445894
Number of Individuals Covered	282
Insurance policy start date	2010-03-01
Insurance policy end date	2011-02-28
Total amount of commissions paid to insurance broker	USD $10,227
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
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 $120,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,227
Insurance broker organization code?	3
Insurance broker name	NICO INSURANCE SERVICES INC.

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Company Name:	KENNON S. SHEA & ASSOCIATES
Employer identification number (EIN):	330685582
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities