JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 401k Plan overview

Plan Name	JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN
Plan identification number	502

JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

JOSHEN PAPER & PACKAGING CO. INC has sponsored the creation of one or more 401k plans.

Company Name:	JOSHEN PAPER & PACKAGING CO. INC
Employer identification number (EIN):	341586752
NAIC Classification:	424100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2022-01-01
502	2021-01-01
502	2020-01-01
502	2019-01-01
502	2018-01-01
502	2017-01-01	ROBERT REINER
502	2016-01-01	ROBERT REINER
502	2015-01-01	ROBERT REINER
502	2014-01-01	ROBERT REINER
502	2013-01-01	ROBERT REINER
502	2012-01-01	ROBERT REINER
502	2011-01-01	ROBERT REINER
502	2010-01-01	ROBERT REINER
502	2009-01-01	ROBERT REINER
502	2009-01-01	ROBERT REINER

Plan Statistics for JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN

401k plan membership statisitcs for JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN

Measure	Date	Value
2022: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	186
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	186
2021: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	300
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	212
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	212
2020: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	350
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	287
Number of retired or separated participants receiving benefits	2020-01-01	13
Total of all active and inactive participants	2020-01-01	300
2019: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	350
Number of retired or separated participants receiving benefits	2019-01-01	6
Total of all active and inactive participants	2019-01-01	356
2018: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	457
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	285
Total of all active and inactive participants	2018-01-01	285
2017: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	455
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	457
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	457
2016: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	450
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	455
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	455
2015: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	440
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	450
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	450
2014: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	432
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	440
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	440
2013: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	429
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	432
Total of all active and inactive participants	2013-01-01	432
2012: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	432
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	429
Total of all active and inactive participants	2012-01-01	429
2011: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	378
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	432
Total of all active and inactive participants	2011-01-01	432
2010: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	374
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	378
Total of all active and inactive participants	2010-01-01	378
2009: JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	359
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	374
Total of all active and inactive participants	2009-01-01	374

Financial Data on JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN

Measure	Date	Value
2017 : JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2017 401k financial data
Total income from all sources	2017-12-31	$0
Total plan assets at end of year	2017-12-31	$0
Total plan assets at beginning of year	2017-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$0
2016 : JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2016 401k financial data
Total income from all sources	2016-12-31	$0
Total plan assets at end of year	2016-12-31	$0
Total plan assets at beginning of year	2016-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$0
2015 : JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2015 401k financial data
Total income from all sources	2015-12-31	$0
Total plan assets at end of year	2015-12-31	$0
Total plan assets at beginning of year	2015-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2015-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2015-12-31	$0
2014 : JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2014 401k financial data
Total income from all sources	2014-12-31	$0
Total plan assets at end of year	2014-12-31	$0
Total plan assets at beginning of year	2014-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$0
2013 : JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2013 401k financial data
Total income from all sources	2013-12-31	$0
Total plan assets at end of year	2013-12-31	$0
Total plan assets at beginning of year	2013-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$0
2012 : JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2012 401k financial data
Total income from all sources	2012-12-31	$0
Total plan assets at end of year	2012-12-31	$0
Total plan assets at beginning of year	2012-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$0
2011 : JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2011 401k financial data
Total income from all sources	2011-12-31	$0
Total plan assets at end of year	2011-12-31	$0
Total plan assets at beginning of year	2011-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$0
2010 : JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN 2010 401k financial data
Total plan assets at end of year	2010-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$0

Form 5500 Responses for JOSHEN PAPER & PACKAGING CO. HEALTH INSURANCE PLAN

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

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0014
Policy instance	4
Insurance contract or identification number 605054 0014 Number of Individuals Covered 3 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $38 Total amount of fees paid to insurance company USD $1 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $125 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0013
Policy instance	15
Insurance contract or identification number 605054 0013 Number of Individuals Covered 22 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $256 Total amount of fees paid to insurance company USD $4 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $852 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $256 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0010
Policy instance	14
Insurance contract or identification number 605054 0010 Number of Individuals Covered 25 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $290 Total amount of fees paid to insurance company USD $6 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $290 Amount paid for insurance broker fees 6 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0009
Policy instance	13
Insurance contract or identification number 605054 0009 Number of Individuals Covered 28 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $339 Total amount of fees paid to insurance company USD $6 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,131 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $339 Amount paid for insurance broker fees 6 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0008
Policy instance	12
Insurance contract or identification number 605054 0008 Number of Individuals Covered 105 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $1,267 Total amount of fees paid to insurance company USD $21 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,253 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,267 Amount paid for insurance broker fees 21 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0007
Policy instance	11
Insurance contract or identification number 605054 0007 Number of Individuals Covered 19 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $183 Total amount of fees paid to insurance company USD $4 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $752 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $183 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0004
Policy instance	10
Insurance contract or identification number 605054 0004 Number of Individuals Covered 19 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $221 Total amount of fees paid to insurance company USD $4 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $737 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $221 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0003
Policy instance	9
Insurance contract or identification number 605054 0003 Number of Individuals Covered 13 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $145 Total amount of fees paid to insurance company USD $3 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $551 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $145 Amount paid for insurance broker fees 3 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	914196
Policy instance	3
Insurance contract or identification number 914196 Number of Individuals Covered 242 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $6,867 Total amount of fees paid to insurance company USD $391 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $106,247 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,867 Insurance broker organization code? 3 Amount paid for insurance broker fees 391 Additional information about fees paid to insurance broker BONUS
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number	W42561
Policy instance	2
Insurance contract or identification number W42561 Number of Individuals Covered 360 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,701 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008734478
Policy instance	1
Insurance contract or identification number 0008734478 Number of Individuals Covered 73 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $1,456 Total amount of fees paid to insurance company USD $135 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit 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 $24,450 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,160 Amount paid for insurance broker fees 81 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0002
Policy instance	8
Insurance contract or identification number 605054 0002 Number of Individuals Covered 28 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $287 Total amount of fees paid to insurance company USD $6 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,182 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $287 Amount paid for insurance broker fees 6 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0001
Policy instance	7
Insurance contract or identification number 605054 0001 Number of Individuals Covered 0 Insurance policy start date 2021-08-01 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $25 Total amount of fees paid to insurance company USD $1 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $24 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054
Policy instance	6
Insurance contract or identification number 605054 Number of Individuals Covered 263 Insurance policy start date 2021-05-02 Insurance policy end date 2022-05-01 Total amount of commissions paid to insurance broker USD $5,115 Total amount of fees paid to insurance company USD $157 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,080 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,115 Amount paid for insurance broker fees 157 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0015
Policy instance	5
Insurance contract or identification number 605054 0015 Number of Individuals Covered 1 Insurance policy start date 2021-08-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $13 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $43 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 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	878148
Policy instance	16
Insurance contract or identification number 878148 Number of Individuals Covered 72 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $6,916 Total amount of fees paid to insurance company USD $147 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $46,106 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,916 Amount paid for insurance broker fees 147 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0536631
Policy instance	17
Insurance contract or identification number R0536631 Number of Individuals Covered 50 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $1,144 Total amount of fees paid to insurance company USD $33 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided GCIEE 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 $21,669 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $650 Insurance broker organization code? 3 Amount paid for insurance broker fees 33 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0536631
Policy instance	32
Insurance contract or identification number R0536631 Number of Individuals Covered 45 Insurance policy start date 2022-08-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $289 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided GCIEE 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 $7,753 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $230 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0015
Policy instance	31
Insurance contract or identification number 605054 0015 Number of Individuals Covered 1 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $12 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $38 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 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0014
Policy instance	30
Insurance contract or identification number 605054 0014 Number of Individuals Covered 3 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $26 Total amount of fees paid to insurance company USD $1 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $88 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $26 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0013
Policy instance	29
Insurance contract or identification number 605054 0013 Number of Individuals Covered 18 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $177 Total amount of fees paid to insurance company USD $9 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $591 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $177 Amount paid for insurance broker fees 9 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0010
Policy instance	28
Insurance contract or identification number 605054 0010 Number of Individuals Covered 22 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $223 Total amount of fees paid to insurance company USD $11 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $744 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $223 Amount paid for insurance broker fees 11 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0009
Policy instance	27
Insurance contract or identification number 605054 0009 Number of Individuals Covered 25 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $241 Total amount of fees paid to insurance company USD $12 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $804 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $241 Amount paid for insurance broker fees 12 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0008
Policy instance	26
Insurance contract or identification number 605054 0008 Number of Individuals Covered 88 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $832 Total amount of fees paid to insurance company USD $41 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,744 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $832 Amount paid for insurance broker fees 41 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0007
Policy instance	25
Insurance contract or identification number 605054 0007 Number of Individuals Covered 8 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $80 Total amount of fees paid to insurance company USD $3 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $123 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $80 Amount paid for insurance broker fees 3 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0004
Policy instance	24
Insurance contract or identification number 605054 0004 Number of Individuals Covered 19 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $192 Total amount of fees paid to insurance company USD $8 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $639 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $192 Amount paid for insurance broker fees 8 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	924089
Policy instance	18
Insurance contract or identification number 924089 Number of Individuals Covered 345 Insurance policy start date 2021-04-01 Insurance policy end date 2022-03-31 Total amount of commissions paid to insurance broker USD $80,256 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No 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 $1,972,766 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $80,256 Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008734478
Policy instance	19
Insurance contract or identification number 0008734478 Number of Individuals Covered 55 Insurance policy start date 2022-08-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $138 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit 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 $7,276 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $83 Insurance broker organization code? 3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	924089
Policy instance	20
Insurance contract or identification number 924089 Number of Individuals Covered 293 Insurance policy start date 2022-04-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $59,968 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,740,616 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 59968 Additional information about fees paid to insurance broker SERVICE FEE AGREEMENT Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054
Policy instance	21
Insurance contract or identification number 605054 Number of Individuals Covered 210 Insurance policy start date 2022-05-02 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $2,039 Total amount of fees paid to insurance company USD $95 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,795 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,039 Amount paid for insurance broker fees 95 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0002
Policy instance	22
Insurance contract or identification number 605054 0002 Number of Individuals Covered 17 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $166 Total amount of fees paid to insurance company USD $6 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $329 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $166 Amount paid for insurance broker fees 6 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0003
Policy instance	23
Insurance contract or identification number 605054 0003 Number of Individuals Covered 9 Insurance policy start date 2022-05-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $90 Total amount of fees paid to insurance company USD $4 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $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 $90 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0001
Policy instance	9
Insurance contract or identification number 605054 0001 Number of Individuals Covered 6 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $129 Total amount of fees paid to insurance company USD $7 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $639 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $129 Amount paid for insurance broker fees 7 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054
Policy instance	8
Insurance contract or identification number 605054 Number of Individuals Covered 290 Insurance policy start date 2020-05-02 Insurance policy end date 2021-05-01 Total amount of commissions paid to insurance broker USD $10,164 Total amount of fees paid to insurance company USD $574 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $53,922 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,164 Amount paid for insurance broker fees 574 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0015
Policy instance	7
Insurance contract or identification number 605054 0015 Number of Individuals Covered 1 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $45 Total amount of fees paid to insurance company USD $2 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $216 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $45 Amount paid for insurance broker fees 2 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0014
Policy instance	6
Insurance contract or identification number 605054 0014 Number of Individuals Covered 3 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $69 Total amount of fees paid to insurance company USD $4 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $309 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $69 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0258939
Policy instance	5
Insurance contract or identification number R0258939 Number of Individuals Covered 0 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided GCIEE 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 $0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Total amount of commissions paid to insurance broker USD $800 Total amount of fees paid to insurance company USD $37 Commission paid to Insurance Broker USD $435 Amount paid for insurance broker fees 37 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	914196
Policy instance	4
Insurance contract or identification number 914196 Number of Individuals Covered 226 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $5,941 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $108,111 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,941 Insurance broker organization code? 3
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number	0075559-01
Policy instance	3
Insurance contract or identification number 0075559-01 Number of Individuals Covered 232 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $85,276 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No 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 $8,966 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $85,276 Insurance broker organization code? 3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number	W42561
Policy instance	2
Insurance contract or identification number W42561 Number of Individuals Covered 360 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,504 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0002
Policy instance	10
Insurance contract or identification number 605054 0002 Number of Individuals Covered 29 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $795 Total amount of fees paid to insurance company USD $43 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,770 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $795 Amount paid for insurance broker fees 43 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0003
Policy instance	11
Insurance contract or identification number 605054 0003 Number of Individuals Covered 14 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $387 Total amount of fees paid to insurance company USD $21 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,828 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $387 Amount paid for insurance broker fees 21 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0004
Policy instance	12
Insurance contract or identification number 605054 0004 Number of Individuals Covered 19 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $818 Total amount of fees paid to insurance company USD $45 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,040 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $818 Amount paid for insurance broker fees 45 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0536631
Policy instance	19
Insurance contract or identification number R0536631 Number of Individuals Covered 58 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $1,454 Total amount of fees paid to insurance company USD $69 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided GCIEE 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 $20,308 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $804 Amount paid for insurance broker fees 69 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	878148
Policy instance	18
Insurance contract or identification number 878148 Number of Individuals Covered 81 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $8,440 Total amount of fees paid to insurance company USD $1,103 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $50,550 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,440 Amount paid for insurance broker fees 1103 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008734478
Policy instance	1
Insurance contract or identification number 0008734478 Number of Individuals Covered 91 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $2,169 Total amount of fees paid to insurance company USD $230 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit 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 $22,410 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,858 Amount paid for insurance broker fees 138 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0013
Policy instance	17
Insurance contract or identification number 605054 0013 Number of Individuals Covered 22 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $620 Total amount of fees paid to insurance company USD $33 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,987 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $620 Amount paid for insurance broker fees 33 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0010
Policy instance	16
Insurance contract or identification number 605054 0010 Number of Individuals Covered 26 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $858 Total amount of fees paid to insurance company USD $47 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,935 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $858 Amount paid for insurance broker fees 47 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0009
Policy instance	15
Insurance contract or identification number 605054 0009 Number of Individuals Covered 28 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $729 Total amount of fees paid to insurance company USD $39 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,462 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $729 Amount paid for insurance broker fees 39 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0008
Policy instance	14
Insurance contract or identification number 605054 0008 Number of Individuals Covered 106 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $3,239 Total amount of fees paid to insurance company USD $175 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,643 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,239 Amount paid for insurance broker fees 175 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0007
Policy instance	13
Insurance contract or identification number 605054 0007 Number of Individuals Covered 19 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $534 Total amount of fees paid to insurance company USD $29 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,553 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $534 Amount paid for insurance broker fees 29 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0258939
Policy instance	6
Insurance contract or identification number R0258939 Number of Individuals Covered 64 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $1,135 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided GCIEE Welfare Benefit Premiums Paid to Carrier USD $22,016 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,135 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0011
Policy instance	7
Insurance contract or identification number 605054 0011 Number of Individuals Covered 6 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $54 Total amount of fees paid to insurance company USD $2 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $366 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $61 Amount paid for insurance broker fees 2 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0012
Policy instance	8
Insurance contract or identification number 605054 0012 Number of Individuals Covered 6 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $3 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $22 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 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0014
Policy instance	9
Insurance contract or identification number 605054 0014 Number of Individuals Covered 4 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $33 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $162 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0015
Policy instance	10
Insurance contract or identification number 605054 0015 Number of Individuals Covered 6 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $21 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $105 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
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054
Policy instance	11
Insurance contract or identification number 605054 Number of Individuals Covered 299 Insurance policy start date 2019-05-02 Insurance policy end date 2020-05-01 Total amount of commissions paid to insurance broker USD $6,171 Total amount of fees paid to insurance company USD $228 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $44,661 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,655 Amount paid for insurance broker fees 202 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	914196
Policy instance	5
Insurance contract or identification number 914196 Number of Individuals Covered 258 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $7,961 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $121,725 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,257 Insurance broker organization code? 3
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number	0075559-01
Policy instance	4
Insurance contract or identification number 0075559-01 Number of Individuals Covered 275 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $90,212 Total amount of fees paid to insurance company USD $47,421 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,205 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $76,668 Amount paid for insurance broker fees 47421 Additional information about fees paid to insurance broker BONUSES, OVERRIDES Insurance broker organization code? 3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number	W42561
Policy instance	3
Insurance contract or identification number W42561 Number of Individuals Covered 270 Insurance policy start date 2019-08-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $11,212 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	00247957
Policy instance	2
Insurance contract or identification number 00247957 Number of Individuals Covered 358 Insurance policy start date 2019-08-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $8,451 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $72,527 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,451 Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008734478
Policy instance	1
Insurance contract or identification number 0008734478 Number of Individuals Covered 91 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $1,133 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $24,233 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,133 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0003
Policy instance	11
Insurance contract or identification number 605054 0003 Number of Individuals Covered 15 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $260 Total amount of fees paid to insurance company USD $13 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,736 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $260 Amount paid for insurance broker fees 13 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0002
Policy instance	10
Insurance contract or identification number 605054 0002 Number of Individuals Covered 32 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $460 Total amount of fees paid to insurance company USD $23 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,053 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $460 Amount paid for insurance broker fees 23 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0001
Policy instance	9
Insurance contract or identification number 605054 0001 Number of Individuals Covered 7 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $84 Total amount of fees paid to insurance company USD $4 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $558 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $84 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0258939
Policy instance	8
Insurance contract or identification number R0258939 Number of Individuals Covered 70 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $857 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided GCIEE Welfare Benefit Premiums Paid to Carrier USD $21,875 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $857 Insurance broker organization code? 3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	914196
Policy instance	7
Insurance contract or identification number 914196 Number of Individuals Covered 285 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $8,478 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $152,049 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,478 Insurance broker organization code? 3
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number	0075559-01
Policy instance	6
Insurance contract or identification number 0075559-01 Number of Individuals Covered 290 Insurance policy start date 2019-04-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $31,335 Total amount of fees paid to insurance company USD $34,949 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,027 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31,335 Amount paid for insurance broker fees 34949 Insurance broker organization code? 3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number	00247957
Policy instance	5
Insurance contract or identification number 00247957 Number of Individuals Covered 293 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $557 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $13,458 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $557 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	00247957
Policy instance	4
Insurance contract or identification number 00247957 Number of Individuals Covered 331 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $9,082 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $82,884 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,082 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0287201
Policy instance	3
Insurance contract or identification number 0287201 Number of Individuals Covered 276 Insurance policy start date 2018-08-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $761,572 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 )
Policy contract number	0287201HNO
Policy instance	2
Insurance contract or identification number 0287201HNO Number of Individuals Covered 248 Insurance policy start date 2018-08-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $616,164 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008734478
Policy instance	1
Insurance contract or identification number 0008734478 Number of Individuals Covered 102 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $487 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $24,818 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $487 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0004
Policy instance	12
Insurance contract or identification number 605054 0004 Number of Individuals Covered 41 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $666 Total amount of fees paid to insurance company USD $33 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,443 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $666 Amount paid for insurance broker fees 33 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0007
Policy instance	13
Insurance contract or identification number 605054 0007 Number of Individuals Covered 21 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $269 Total amount of fees paid to insurance company USD $13 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,797 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $269 Amount paid for insurance broker fees 13 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0009
Policy instance	15
Insurance contract or identification number 605054 0009 Number of Individuals Covered 40 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $551 Total amount of fees paid to insurance company USD $28 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,675 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $551 Amount paid for insurance broker fees 28 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0010
Policy instance	16
Insurance contract or identification number 605054 0010 Number of Individuals Covered 39 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $586 Total amount of fees paid to insurance company USD $29 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,906 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $586 Amount paid for insurance broker fees 29 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0011
Policy instance	17
Insurance contract or identification number 605054 0011 Number of Individuals Covered 10 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $139 Total amount of fees paid to insurance company USD $7 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $928 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $139 Amount paid for insurance broker fees 7 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0012
Policy instance	18
Insurance contract or identification number 605054 0012 Number of Individuals Covered 2 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $36 Total amount of fees paid to insurance company USD $2 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $241 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36 Amount paid for insurance broker fees 2 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0013
Policy instance	19
Insurance contract or identification number 605054 0013 Number of Individuals Covered 21 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $306 Total amount of fees paid to insurance company USD $15 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,039 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $306 Amount paid for insurance broker fees 15 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054 0008
Policy instance	14
Insurance contract or identification number 605054 0008 Number of Individuals Covered 131 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $2,255 Total amount of fees paid to insurance company USD $113 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $15,031 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,255 Amount paid for insurance broker fees 113 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0536631
Policy instance	2
Insurance contract or identification number R0536631 Number of Individuals Covered 77 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $2,089 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided GCIEE Welfare Benefit Premiums Paid to Carrier USD $21,987 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,089 Insurance broker organization code? 3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number
Policy instance	6
Number of Individuals Covered 0 Insurance policy start date 2018-01-01 Insurance policy end date 2018-08-31 Total amount of commissions paid to insurance broker USD $4,545 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $75,618 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,545 Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0287201
Policy instance	5
Insurance contract or identification number 0287201 Number of Individuals Covered 285 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $995,876 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0287201HNO
Policy instance	4
Insurance contract or identification number 0287201HNO Number of Individuals Covered 46 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $8,015 Welfare Benefit Premiums Paid to Carrier USD $735,647 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 8015 Additional information about fees paid to insurance broker 2017 PPP ENGAGEMENT CREDIT - NEW BUSINESS MEDICAL Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008734478
Policy instance	3
Insurance contract or identification number 0008734478 Number of Individuals Covered 121 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $2,378 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $28,762 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,378 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054
Policy instance	1
Insurance contract or identification number 605054 Number of Individuals Covered 134 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $5,593 Total amount of fees paid to insurance company USD $280 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $38,292 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,593 Amount paid for insurance broker fees 280 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0008734478
Policy instance	4
Insurance contract or identification number 0008734478 Number of Individuals Covered 126 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,410 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $29,620 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,410 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0258939
Policy instance	3
Insurance contract or identification number R0258939 Number of Individuals Covered 81 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,389 Other welfare benefits provided GCIEE Welfare Benefit Premiums Paid to Carrier USD $22,810 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,389 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP INC
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number	466237
Policy instance	2
Insurance contract or identification number 466237 Number of Individuals Covered 457 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $72,636 Total amount of fees paid to insurance company USD $8,280 Vision Insurance Welfare Benefit Yes Other welfare benefits provided HEALTH PPO Welfare Benefit Premiums Paid to Carrier USD $1,830,302 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $72,636 Amount paid for insurance broker fees 8280 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054
Policy instance	1
Insurance contract or identification number 605054 Number of Individuals Covered 134 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $5,872 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $38,292 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,872 Insurance broker organization code? 3 Insurance broker name THE FEDELI GROUP INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	000TL535
Policy instance	2
Insurance contract or identification number 000TL535 Number of Individuals Covered 303 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,726 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $32,084 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,726 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3333107
Policy instance	3
Insurance contract or identification number 3333107 Number of Individuals Covered 420 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $85,853 Total amount of fees paid to insurance company USD $26,726 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Other welfare benefits provided PREPAID DENTAL Welfare Benefit Premiums Paid to Carrier USD $623,645 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $85,853 Amount paid for insurance broker fees 26726 Insurance broker organization code? 3 Insurance broker name THE FIDELI GROUP INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054
Policy instance	1
Insurance contract or identification number 605054 Number of Individuals Covered 411 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $4,054 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $25,742 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,054 Insurance broker organization code? 3 Insurance broker name THE FEDELI GROUP INC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3333107
Policy instance	3
Insurance contract or identification number 3333107 Number of Individuals Covered 409 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $83,496 Total amount of fees paid to insurance company USD $25,155 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Other welfare benefits provided PREPAID DENTAL Welfare Benefit Premiums Paid to Carrier USD $585,911 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $83,496 Amount paid for insurance broker fees 25155 Insurance broker organization code? 3 Insurance broker name THE FIDELI GROUP INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	000TL535
Policy instance	2
Insurance contract or identification number 000TL535 Number of Individuals Covered 375 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $8,437 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $60,985 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,437 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	605054
Policy instance	1
Insurance contract or identification number 605054 Number of Individuals Covered 406 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,796 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $28,208 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,796 Insurance broker organization code? 3 Insurance broker name THE FEDELI GROUP INC
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	8734478
Policy instance	5
Insurance contract or identification number 8734478 Number of Individuals Covered 72 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $601 Other welfare benefits provided ACCIDENT CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $19,256 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $601 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	000TL535
Policy instance	4
Insurance contract or identification number 000TL535 Number of Individuals Covered 375 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $8,437 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $60,985 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,437 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	3333107
Policy instance	3
Insurance contract or identification number 3333107 Number of Individuals Covered 362 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $11,500 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $179,654 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,500 Insurance broker organization code? 3 Insurance broker name THE FEDELI GROUP INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0258939
Policy instance	2
Insurance contract or identification number R0258939 Number of Individuals Covered 152 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $10,223 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $62,258 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,223 Insurance broker organization code? 3 Insurance broker name THE FEDELI GROUP INC
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 96518 )
Policy contract number	846861-HNO
Policy instance	1
Insurance contract or identification number 846861-HNO Number of Individuals Covered 323 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $47,843 Total amount of fees paid to insurance company USD $17,640 Welfare Benefit Premiums Paid to Carrier USD $1,156,721 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,843 Amount paid for insurance broker fees 17640 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	846861
Policy instance	6
Insurance contract or identification number 846861 Number of Individuals Covered 226 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $31,288 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $759,634 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31,288 Insurance broker organization code? 3 Insurance broker name FEDELI GROUP
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0258939
Policy instance	2
Insurance contract or identification number R0258939 Number of Individuals Covered 177 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $10,339 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $72,769 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,339 Insurance broker organization code? 3 Insurance broker name THE FIDELI GROUP INC
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	3333107
Policy instance	3
Insurance contract or identification number 3333107 Number of Individuals Covered 359 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $11,045 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $173,844 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,045 Insurance broker organization code? 3 Insurance broker name THE FIDELI GROUP INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	000TL535
Policy instance	4
Insurance contract or identification number 000TL535 Number of Individuals Covered 371 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $8,423 Total amount of fees paid to insurance company USD $1,918 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $58,685 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,423 Amount paid for insurance broker fees 1918 Insurance broker organization code? 3 Insurance broker name FIDELI GROUP
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	000TL12
Policy instance	5
Insurance contract or identification number 000TL12 Number of Individuals Covered 371 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $278 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,937 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $278 Insurance broker organization code? 3 Insurance broker name LIFETIME FINANCIAL GROWTH OF NO OH
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	0714708
Policy instance	1
Insurance contract or identification number 0714708 Number of Individuals Covered 290 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $85,796 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,906,578 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $85,796 Insurance broker organization code? 3 Insurance broker name FIDELI GROUP
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	3333107
Policy instance	3
Insurance contract or identification number 3333107 Number of Individuals Covered 340 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $11,154 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $170,954 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	0714708
Policy instance	1
Insurance contract or identification number 0714708 Number of Individuals Covered 290 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $88,977 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,705,402 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0258939
Policy instance	2
Insurance contract or identification number R0258939 Number of Individuals Covered 432 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $19,179 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $714,614 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	R0258939
Policy instance	4
Insurance contract or identification number R0258939 Number of Individuals Covered 360 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $18,530 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $117,098 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	12222961
Policy instance	6
Insurance contract or identification number 12222961 Number of Individuals Covered 57 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $748 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $9,945 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	0714708
Policy instance	3
Insurance contract or identification number 0714708 Number of Individuals Covered 324 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $100,505 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,101,940 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TM05722546
Policy instance	2
Insurance contract or identification number TM05722546 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,092 Total amount of fees paid to insurance company USD $273 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	GLT-85 1574
Policy instance	1
Insurance contract or identification number GLT-85 1574 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $17 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $113 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	3333107
Policy instance	5
Insurance contract or identification number 3333107 Number of Individuals Covered 327 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $10,848 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $164,940 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No