401k Plan data: DUTCH CORPORATION MEDICAL BENEFIT PLAN plan

DUTCH CORPORATION MEDICAL BENEFIT PLAN 401k Plan overview

Plan Name	DUTCH CORPORATION MEDICAL BENEFIT PLAN
Plan identification number	501

DUTCH CORPORATION MEDICAL BENEFIT PLAN Benefits

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

401k Sponsoring company profile

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

Company Name: DUTCHMAN HOSPITALITY GROUP, INC.

Employer identification number (EIN): 341038011

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Additional information about DUTCHMAN HOSPITALITY GROUP, INC.

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division

Incorporation Date: 1969-05-02

Company Identification Number: 383681

Legal Registered Office Address: 4985 WALNUT STREET
-
WALNUT CREEK
United States of America (USA)
44687

More information about DUTCHMAN HOSPITALITY GROUP, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DUTCH CORPORATION MEDICAL BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 CAROL MILLER CAROL MILLER 2019-07-11
501 2017-01-01 CAROL MILLER CAROL MILLER 2018-07-30
501 2016-01-01 CAROL MILLER CAROL MILLER 2017-05-08
501 2015-01-01 CAROL MILLER CAROL MILLER 2016-07-25
501 2014-01-01 CAROL MILLER CAROL MILLER 2015-08-04
501 2013-01-01 CAROL MILLER CAROL MILLER 2014-08-19
501 2012-01-01 CAROL MILLER CAROL MILLER 2013-11-14
501 2011-01-01 CAROL MILLER CAROL MILLER 2012-07-12
501 2010-01-01 CAROL MILLER CAROL MILLER 2011-06-20
501 2009-01-01 CAROL MILLER CAROL MILLER 2010-06-24

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01	CAROL MILLER	CAROL MILLER	2019-07-11
501	2017-01-01	CAROL MILLER	CAROL MILLER	2018-07-30
501	2016-01-01	CAROL MILLER	CAROL MILLER	2017-05-08
501	2015-01-01	CAROL MILLER	CAROL MILLER	2016-07-25
501	2014-01-01	CAROL MILLER	CAROL MILLER	2015-08-04
501	2013-01-01	CAROL MILLER	CAROL MILLER	2014-08-19
501	2012-01-01	CAROL MILLER	CAROL MILLER	2013-11-14
501	2011-01-01	CAROL MILLER	CAROL MILLER	2012-07-12
501	2010-01-01	CAROL MILLER	CAROL MILLER	2011-06-20
501	2009-01-01	CAROL MILLER	CAROL MILLER	2010-06-24

Plan Statistics for DUTCH CORPORATION MEDICAL BENEFIT PLAN

401k plan membership statisitcs for DUTCH CORPORATION MEDICAL BENEFIT PLAN

Measure Date Value
2022: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 197
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 335
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 335
2021: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 222
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 197
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 197
2020: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 249
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 222
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 222
2019: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 234
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 249
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 249
Number of employers contributing to the scheme 2019-01-01 0
2018: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 209
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 234
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 234
Number of employers contributing to the scheme 2018-01-01 0
2017: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 221
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 209
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 209
2016: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 138
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 221
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 221
2015: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 152
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 138
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 138
2014: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 143
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 152
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 152
Number of employers contributing to the scheme 2014-01-01 0
2013: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 151
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 143
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 2013-01-01 143
Number of employers contributing to the scheme 2013-01-01 0
2012: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 184
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 151
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 2012-01-01 151
Number of employers contributing to the scheme 2012-01-01 0
2011: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 184
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 184
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 2011-01-01 184
Number of employers contributing to the scheme 2011-01-01 0
2010: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 185
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 184
Total of all active and inactive participants 2010-01-01 184
2009: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 176
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 185
Total of all active and inactive participants 2009-01-01 185

Measure	Date	Value
2022: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	197
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	335
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	335
2021: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	222
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	197
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	197
2020: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	249
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	222
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	222
2019: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	234
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	249
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	249
Number of employers contributing to the scheme	2019-01-01	0
2018: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	209
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	234
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	234
Number of employers contributing to the scheme	2018-01-01	0
2017: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	221
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	209
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	209
2016: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	221
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	221
2015: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	152
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	138
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	138
2014: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	143
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	152
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	152
Number of employers contributing to the scheme	2014-01-01	0
2013: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	151
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	143
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	143
Number of employers contributing to the scheme	2013-01-01	0
2012: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	184
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	151
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	151
Number of employers contributing to the scheme	2012-01-01	0
2011: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	184
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	184
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	184
Number of employers contributing to the scheme	2011-01-01	0
2010: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	185
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	184
Total of all active and inactive participants	2010-01-01	184
2009: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	176
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	185
Total of all active and inactive participants	2009-01-01	185

Form 5500 Responses for DUTCH CORPORATION MEDICAL BENEFIT PLAN

2022: DUTCH CORPORATION MEDICAL 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: DUTCH CORPORATION MEDICAL 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: DUTCH CORPORATION MEDICAL 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: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Multi-employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Multi-employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Multi-employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Multi-employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Multi-employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Multi-employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Multi-employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Multi-employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Multi-employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Multi-employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: DUTCH CORPORATION MEDICAL BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Multi-employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

169774

Policy instance

Insurance contract or identification number	169774
Number of Individuals Covered	195
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $27,395
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,956
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	36
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,208
Welfare Benefit Premiums Paid to Carrier	USD $21,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,343
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	CONT SVCS

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

I002458

Policy instance

Insurance contract or identification number	I002458
Number of Individuals Covered	335
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $37,515
Health 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 $37,515
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	45
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,574
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $92
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29
Additional information about fees paid to insurance broker	CONTRACT SERVICES
Insurance broker organization code?	3

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	4
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $372
Total amount of fees paid to insurance company	USD $164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $372
Amount paid for insurance broker fees	164

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

I002458

Policy instance

Insurance contract or identification number	I002458
Number of Individuals Covered	197
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $21,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,315
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	30
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,175
Welfare Benefit Premiums Paid to Carrier	USD $24,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,753
Additional information about fees paid to insurance broker	CONT SVCS
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1081716

Policy instance

Insurance contract or identification number	1081716
Number of Individuals Covered	218
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $7,790
Total amount of fees paid to insurance company	USD $4,188
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY)
Welfare Benefit Premiums Paid to Carrier	USD $105,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,790
Amount paid for insurance broker fees	3907
Additional information about fees paid to insurance broker	CONT SVCS
Insurance broker organization code?	3

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $503
Total amount of fees paid to insurance company	USD $257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $503
Amount paid for insurance broker fees	257

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	2
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $163
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
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
Additional information about fees paid to insurance broker	CONTRACT SERVICES
Insurance broker organization code?	3

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	35
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,204
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	7
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $571
Total amount of fees paid to insurance company	USD $384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $571
Amount paid for insurance broker fees	384

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $126
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34
Additional information about fees paid to insurance broker	CONTRACT SERVICES
Insurance broker organization code?	3

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	36
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,899
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

I002458

Policy instance

Insurance contract or identification number	I002458
Number of Individuals Covered	222
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $19,809
Total amount of fees paid to insurance company	USD $29,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,809
Amount paid for insurance broker fees	29047
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	36
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,868
Welfare Benefit Premiums Paid to Carrier	USD $20,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,590
Additional information about fees paid to insurance broker	CONT SVCS
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1081716

Policy instance

Insurance contract or identification number	1081716
Number of Individuals Covered	218
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $13,225
Total amount of fees paid to insurance company	USD $1,583
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY)
Welfare Benefit Premiums Paid to Carrier	USD $108,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,955
Amount paid for insurance broker fees	1583
Additional information about fees paid to insurance broker	CONT SVCS
Insurance broker organization code?	3

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	13
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $960
Total amount of fees paid to insurance company	USD $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 $960
Amount paid for insurance broker fees	100

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	2
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $184
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
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
Additional information about fees paid to insurance broker	CONTRACT SERVICES
Insurance broker organization code?	3

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	38
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,437
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

I002458

Policy instance

Insurance contract or identification number	I002458
Number of Individuals Covered	249
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $21,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,276
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	39
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,858
Welfare Benefit Premiums Paid to Carrier	USD $23,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,400
Additional information about fees paid to insurance broker	CONT SVCS
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1081716

Policy instance

Insurance contract or identification number	1081716
Number of Individuals Covered	247
Insurance policy start date	2018-10-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $11,682
Total amount of fees paid to insurance company	USD $6,231
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	OTHER (SPECIFY)
Welfare Benefit Premiums Paid to Carrier	USD $101,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,918
Amount paid for insurance broker fees	6231
Additional information about fees paid to insurance broker	CONT SVCS
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	35
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,409
Additional information about fees paid to insurance broker	CONT SVCS
Insurance broker organization code?	3

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

I002458

Policy instance

Insurance contract or identification number	I002458
Number of Individuals Covered	234
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $21,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,723
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	40
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,368
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	6
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $393
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $86
Additional information about fees paid to insurance broker	CONTRACT SERVICES
Insurance broker organization code?	3

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	136
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,050
Total amount of fees paid to insurance company	USD $5,496
Health 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 $7,050
Amount paid for insurance broker fees	5496
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	39
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,897
Additional information about fees paid to insurance broker	CONT SVCS
Insurance broker organization code?	3
Insurance broker name	AMERICAN HERITAGE LIFE

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

I002458

Policy instance

Insurance contract or identification number	I002458
Number of Individuals Covered	209
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $20,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,353
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	HUMMEL GROUP, INC.

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	36
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,908
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	HUMMEL GROUP, INC.

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	7
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $483
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $108
Additional information about fees paid to insurance broker	CONTRACT SERVICES
Insurance broker organization code?	3
Insurance broker name	RICO PEREZ

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	125
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,126
Total amount of fees paid to insurance company	USD $3,553
Health 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 $8,561
Amount paid for insurance broker fees	3553
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	HUMMEL GROUP, INC.

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	21
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,241
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,241
Additional information about fees paid to insurance broker	CONTRACT SERV. 3
Insurance broker name	AFLAC

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	32
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $536
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

Policy instance

Number of Individuals Covered	138
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $19,282
Total amount of fees paid to insurance company	USD $1
Welfare Benefit Premiums Paid to Carrier	USD $8,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,282
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	HUMMEL GROUP, INC.

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	53
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	CONTRACT SVC
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $1,047
Insurance broker name	MARK JONES

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	124
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,053
Total amount of fees paid to insurance company	USD $3,258
Health 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 $1,216
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION 3
Amount paid for insurance broker fees	3258
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL INC

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

Policy instance

Number of Individuals Covered	152
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $21,206
Welfare Benefit Premiums Paid to Carrier	USD $9,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,206
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	HUMMEL GROUP, INC.

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	28
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,588
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,588
Additional information about fees paid to insurance broker	CONTRACT SERV. 3
Insurance broker name	AFLAC

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	131
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,938
Total amount of fees paid to insurance company	USD $3,047
Health 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 $2,757
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION 3
Amount paid for insurance broker fees	3047
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL INC

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	32
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $566
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	70
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	CONTRACT SVC
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $1,385
Insurance broker name	BRIAN KAUFFMAN

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

Policy contract number

U37008

Policy instance

Insurance contract or identification number	U37008
Number of Individuals Covered	33
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,491
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,491
Additional information about fees paid to insurance broker	CONTRACT SERV. 3
Insurance broker name	AFLAC

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG570-85

Policy instance

Insurance contract or identification number	LG570-85
Number of Individuals Covered	79
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $15,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	CONTRACT SVC
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $4,381
Insurance broker name	MARK JONES

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

Policy instance

Number of Individuals Covered	100
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $13,836
Welfare Benefit Premiums Paid to Carrier	USD $6,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,836
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	HUMMEL GROUP, INC.

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	28
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $480
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	143
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,786
Total amount of fees paid to insurance company	USD $1,470
Health 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 $1,136
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION 3
Amount paid for insurance broker fees	1470
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL INC

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

Policy contract number

00479320

Policy instance

Insurance contract or identification number	00479320
Number of Individuals Covered	151
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,671
Health 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 $501
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION 3
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL INC

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

Policy contract number

9022573044

Policy instance

Insurance contract or identification number	9022573044
Number of Individuals Covered	39
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $182
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

Policy instance

Number of Individuals Covered	109
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,418
Total amount of fees paid to insurance company	USD $6,744
Welfare Benefit Premiums Paid to Carrier	USD $6,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,418
Amount paid for insurance broker fees	6744
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	HUMMEL GROUP, INC.

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

LG575-78

Policy instance

Insurance contract or identification number	LG575-78
Number of Individuals Covered	36
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,843
Additional information about fees paid to insurance broker	CONTRACT SVC 3
Insurance broker name	AMERICAN HERITAGE LIFE

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

Policy instance

Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

U37008

Policy instance

Insurance contract or identification number	U37008
Number of Individuals Covered	42
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,242
Total amount of fees paid to insurance company	USD $101
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,242
Amount paid for insurance broker fees	101
Additional information about fees paid to insurance broker	CONTRACT SERV. 3
Insurance broker name	AFLAC

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

Policy contract number

U37008

Policy instance

Insurance contract or identification number	U37008
Number of Individuals Covered	42
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,598
Total amount of fees paid to insurance company	USD $242
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

I950202

Policy instance

Insurance contract or identification number	I950202
Number of Individuals Covered	299
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $20,450
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

U3708

Policy instance

Insurance contract or identification number	U3708
Number of Individuals Covered	48
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,139
Total amount of fees paid to insurance company	USD $112
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,139
Amount paid for insurance broker fees	112
Additional information about fees paid to insurance broker	CONTRACT SERV
Insurance broker organization code?	3
Insurance broker name	AFLAC

AULTCARE (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

I950202

Policy instance

Insurance contract or identification number	I950202
Number of Individuals Covered	321
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $21,295
Health 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 $21,295
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	HUMMEL GROUP, INC.

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Company Name:	DUTCHMAN HOSPITALITY GROUP, INC.
Employer identification number (EIN):	341038011
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants

Jurisdiction of Incorporation:	Ohio Secretary of State Business Services Division
Incorporation Date:	1969-05-02
Company Identification Number:	383681
Legal Registered Office Address:	4985 WALNUT STREET - WALNUT CREEK United States of America (USA) 44687