401k Plan data: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN plan

THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 401k Plan overview

Plan Name	THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN
Plan identification number	501

THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN Benefits

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

401k Sponsoring company profile

FARMERS AND MERCHANTS STATE BANK has sponsored the creation of one or more 401k plans.

Company Name: FARMERS AND MERCHANTS STATE BANK

Employer identification number (EIN): 344230390

NAIC Classification: 522120
NAIC Description: Savings Institutions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 DIANN MEYER-GRIESER
501 2011-01-01 DIANN MEYER-GRIESER
501 2010-01-01 DIANN MEYER-GRIESER
501 2009-01-01 DIANN MEYER-GRIESER
501 2007-01-01 DIANN MEYER-GRIESER

Plan Statistics for THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN

401k plan membership statisitcs for THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN

Measure Date Value
2021: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 525
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 530
Total of all active and inactive participants 2021-01-01 530
2020: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 215
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 525
Total of all active and inactive participants 2020-01-01 525
2019: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 224
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 215
Total of all active and inactive participants 2019-01-01 215
2018: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 224
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 224
Total of all active and inactive participants 2018-01-01 224
2017: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 221
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 224
Total of all active and inactive participants 2017-01-01 224
2016: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 224
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 221
Total of all active and inactive participants 2016-01-01 221
2015: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 261
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 224
Total of all active and inactive participants 2015-01-01 224
2014: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 216
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 261
Total of all active and inactive participants 2014-01-01 261
2013: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 207
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 216
Total of all active and inactive participants 2013-01-01 216
2012: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 250
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 207
Total of all active and inactive participants 2012-01-01 207
2011: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 237
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 250
Total of all active and inactive participants 2011-01-01 250
2010: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 227
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 237
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 237
2009: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 227
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 227
2007: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2007 401k membership
Total participants, beginning-of-year 2007-01-01 215
Total number of active participants reported on line 7a of the Form 5500 2007-01-01 228
Number of retired or separated participants receiving benefits 2007-01-01 0
Number of other retired or separated participants entitled to future benefits 2007-01-01 0
Total of all active and inactive participants 2007-01-01 228

Measure	Date	Value
2021: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	525
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	530
Total of all active and inactive participants	2021-01-01	530
2020: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	215
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	525
Total of all active and inactive participants	2020-01-01	525
2019: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	224
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	215
Total of all active and inactive participants	2019-01-01	215
2018: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	224
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	224
Total of all active and inactive participants	2018-01-01	224
2017: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	221
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	224
Total of all active and inactive participants	2017-01-01	224
2016: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	224
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	221
Total of all active and inactive participants	2016-01-01	221
2015: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	261
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	224
Total of all active and inactive participants	2015-01-01	224
2014: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	216
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	261
Total of all active and inactive participants	2014-01-01	261
2013: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	207
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	216
Total of all active and inactive participants	2013-01-01	216
2012: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	250
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	207
Total of all active and inactive participants	2012-01-01	207
2011: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	237
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	250
Total of all active and inactive participants	2011-01-01	250
2010: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	227
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	237
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	237
2009: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	227
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	227
2007: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2007 401k membership
Total participants, beginning-of-year	2007-01-01	215
Total number of active participants reported on line 7a of the Form 5500	2007-01-01	228
Number of retired or separated participants receiving benefits	2007-01-01	0
Number of other retired or separated participants entitled to future benefits	2007-01-01	0
Total of all active and inactive participants	2007-01-01	228

Form 5500 Responses for THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN

2021: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF 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 funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2007: THE FARMERS AND MERCHANTS STATE BANK WELFARE BENEF PLAN 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	Plan funding arrangement – Insurance	Yes
2007-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2007-01-01	Plan benefit arrangement – Insurance	Yes
2007-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30072818

Policy instance

Insurance contract or identification number	30072818
Number of Individuals Covered	279
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,488
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,488
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Number of Individuals Covered	314
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $17,077
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $112,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,450
Amount paid for insurance broker fees	0
Insurance broker organization code?	4
Additional information about fees paid to insurance broker	BONUSES

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	83
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,700
Total amount of fees paid to insurance company	USD $327
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 $54,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,847
Amount paid for insurance broker fees	25
Insurance broker organization code?	3

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

Policy contract number

0010022

Policy instance

Insurance contract or identification number	0010022
Number of Individuals Covered	525
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30072818

Policy instance

Insurance contract or identification number	30072818
Number of Individuals Covered	244
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,475
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,475
Insurance broker organization code?	3

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	96
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $13,321
Total amount of fees paid to insurance company	USD $599
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 $67,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,904
Amount paid for insurance broker fees	491
Additional information about fees paid to insurance broker	BONUSES
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30072818

Policy instance

Insurance contract or identification number	30072818
Number of Individuals Covered	215
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,355
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,355
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

918210

Policy instance

Insurance contract or identification number	918210
Number of Individuals Covered	22
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $227
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $227
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	116
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $19,806
Total amount of fees paid to insurance company	USD $1,106
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 $76,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,390
Amount paid for insurance broker fees	1106
Insurance broker organization code?	3

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

Policy instance

Number of Individuals Covered	200
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $27,577
Total amount of fees paid to insurance company	USD $8,871
Welfare Benefit Premiums Paid to Carrier	USD $573,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,577
Amount paid for insurance broker fees	8871
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000406629

Policy instance

Insurance contract or identification number	0000406629
Number of Individuals Covered	12
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,117
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,117
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

6759

Policy instance

Insurance contract or identification number	6759
Number of Individuals Covered	52
Insurance policy start date	2019-05-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,972
Total amount of fees paid to insurance company	USD $4,484
Welfare Benefit Premiums Paid to Carrier	USD $99,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,972
Amount paid for insurance broker fees	4484
Insurance broker organization code?	3

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Number of Individuals Covered	224
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $10,534
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $70,227
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,534
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

Policy instance

Number of Individuals Covered	187
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $25,749
Total amount of fees paid to insurance company	USD $7,268
Welfare Benefit Premiums Paid to Carrier	USD $459,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,749
Amount paid for insurance broker fees	7268
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30072818

Policy instance

Insurance contract or identification number	30072818
Number of Individuals Covered	176
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,139
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,139
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

000406629

Policy instance

Insurance contract or identification number	000406629
Number of Individuals Covered	10
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,588
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,588
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	113
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $12,892
Total amount of fees paid to insurance company	USD $669
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 $64,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,419
Amount paid for insurance broker fees	669
Insurance broker organization code?	3

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

Policy contract number

R0036178

Policy instance

Insurance contract or identification number	R0036178
Number of Individuals Covered	15
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $511
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $511
Insurance broker organization code?	3
Insurance broker name	JC ROSE AND ASSOC LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

30072818

Policy instance

Insurance contract or identification number	30072818
Number of Individuals Covered	152
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,076
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,076
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

Policy instance

Number of Individuals Covered	188
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $25,979
Total amount of fees paid to insurance company	USD $6,842
Welfare Benefit Premiums Paid to Carrier	USD $433,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,979
Amount paid for insurance broker fees	6842
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Number of Individuals Covered	224
Insurance policy start date	2016-09-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $9,621
Total amount of fees paid to insurance company	USD $1,956
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $64,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,621
Amount paid for insurance broker fees	223
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	118
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,364
Total amount of fees paid to insurance company	USD $626
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 $65,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,519
Amount paid for insurance broker fees	626
Insurance broker organization code?	3
Insurance broker name	HEALTHCARE REFORM ALTERNATIVE LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007787674

Policy instance

Insurance contract or identification number	0007787674
Number of Individuals Covered	3
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9
Insurance broker organization code?	3
Insurance broker name	JC ROSE AND ASSOC LLC

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Number of Individuals Covered	224
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,490
Total amount of fees paid to insurance company	USD $1,090
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $56,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,490
Amount paid for insurance broker fees	1090
Additional information about fees paid to insurance broker	BONUSES
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	114
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,108
Total amount of fees paid to insurance company	USD $501
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 $61,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,186
Amount paid for insurance broker fees	335
Insurance broker organization code?	3
Insurance broker name	HEALTHCARE REFORM ALTERNATIVE LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

59149

Policy instance

Insurance contract or identification number	59149
Number of Individuals Covered	40
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,857
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,004
Insurance broker name	WILLIS OF OHIO INC.

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

59149

Policy instance

Insurance contract or identification number	59149
Number of Individuals Covered	40
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $1,857
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,004
Insurance broker name	WILLIS OF OHIO INC.

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	107
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,313
Total amount of fees paid to insurance company	USD $317
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,075
Amount paid for insurance broker fees	313
Insurance broker organization code?	3
Insurance broker name	HEALTHCARE REFORM ALTERNATIVE LLC

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Number of Individuals Covered	261
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,991
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $53,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,991
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

BCA518

Policy instance

Insurance contract or identification number	BCA518
Number of Individuals Covered	200
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,893
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $127,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,893
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	115
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,865
Total amount of fees paid to insurance company	USD $502
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,451
Amount paid for insurance broker fees	445
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	GREGORY A TOMASI

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007787674

Policy instance

Insurance contract or identification number	0007787674
Number of Individuals Covered	8
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $22
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22
Insurance broker organization code?	3
Insurance broker name	JC ROSE AND ASSOC LLB

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Number of Individuals Covered	216
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,626
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $54,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,626
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	114
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,311
Total amount of fees paid to insurance company	USD $476
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,216
Amount paid for insurance broker fees	394
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	PHILIP J. SANDERS

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

BCA518

Policy instance

Insurance contract or identification number	BCA518
Number of Individuals Covered	178
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,941
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $107,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,941
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Number of Individuals Covered	207
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,653
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $50,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,653
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0007787674

Policy instance

Insurance contract or identification number	0007787674
Number of Individuals Covered	13
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $125
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125
Insurance broker organization code?	3
Insurance broker name	DENMAN MAY AND ASSOC INC

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

Policy contract number

220144

Policy instance

Insurance contract or identification number	220144
Number of Individuals Covered	250
Insurance policy start date	2011-09-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,144
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $17,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010092019

Policy instance

Insurance contract or identification number	000010092019
Number of Individuals Covered	0
Insurance policy start date	2011-01-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $1,744
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $26,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010092020

Policy instance

Insurance contract or identification number	000010092020
Number of Individuals Covered	0
Insurance policy start date	2011-01-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $2,001
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,999
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

59149

Policy instance

Insurance contract or identification number	59149
Number of Individuals Covered	51
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,316
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	117
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $9,660
Total amount of fees paid to insurance company	USD $404
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

BCA518

Policy instance

Insurance contract or identification number	BCA518
Number of Individuals Covered	208
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,276
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $142,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010092019

Policy instance

Insurance contract or identification number	000010092019
Number of Individuals Covered	226
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,693
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $39,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,693
Insurance broker organization code?	3
Insurance broker name	DCB INS SERVICES LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010092020

Policy instance

Insurance contract or identification number	000010092020
Number of Individuals Covered	226
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,265
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,265
Insurance broker organization code?	3
Insurance broker name	DCB INS SERVICES LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

59149

Policy instance

Insurance contract or identification number	59149
Number of Individuals Covered	237
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,790
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,843
Insurance broker organization code?	3
Insurance broker name	HILB ROGAL & HOBBS OF OHIO LLC

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	125
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,585
Total amount of fees paid to insurance company	USD $421
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,490
Amount paid for insurance broker fees	374
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	PHILIP J. SANDERS

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

BCA518

Policy instance

Insurance contract or identification number	BCA518
Number of Individuals Covered	190
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,376
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $161,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,376
Insurance broker organization code?	3
Insurance broker name	ANDRES O'NEIL & LOWE AGENCY

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

BCA518

Policy instance

Insurance contract or identification number	BCA518
Number of Individuals Covered	190
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $2,292
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $252,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,292
Insurance broker organization code?	3
Insurance broker name	ANDRES O'NEIL & LOWE AGENCY LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010092019

Policy instance

Insurance contract or identification number	000010092019
Number of Individuals Covered	229
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $2,741
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $37,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,741
Insurance broker organization code?	3
Insurance broker name	DCB INS SERVICES LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010092020

Policy instance

Insurance contract or identification number	000010092020
Number of Individuals Covered	229
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $3,261
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,261
Insurance broker organization code?	3
Insurance broker name	DCB INS SERVICES LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

59149

Policy instance

Insurance contract or identification number	59149
Number of Individuals Covered	39
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $1,535
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $939
Insurance broker organization code?	3
Insurance broker name	HILB ROGAL & HOBBS OF OHIO LLC

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	144
Insurance policy start date	2008-01-01
Insurance policy end date	2008-12-31
Total amount of commissions paid to insurance broker	USD $14,128
Total amount of fees paid to insurance company	USD $1,834
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,504
Amount paid for insurance broker fees	156
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	RICHARD HESLOP

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

246-6213-00

Policy instance

Insurance contract or identification number	246-6213-00
Number of Individuals Covered	228
Insurance policy start date	2006-02-01
Insurance policy end date	2007-01-31
Total amount of commissions paid to insurance broker	USD $2,634
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 $39,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,634
Insurance broker organization code?	3
Insurance broker name	BOAHC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010092019

Policy instance

Insurance contract or identification number	000010092019
Number of Individuals Covered	215
Insurance policy start date	2007-06-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $1,958
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $19,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,958
Insurance broker organization code?	3
Insurance broker name	DCB INS SERVICES LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010092020

Policy instance

Insurance contract or identification number	000010092020
Number of Individuals Covered	224
Insurance policy start date	2007-06-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $1,895
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,895
Insurance broker organization code?	3
Insurance broker name	DCB INS SERVICES LLC

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

59149

Policy instance

Insurance contract or identification number	59149
Number of Individuals Covered	33
Insurance policy start date	2007-01-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $1,664
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,146
Insurance broker organization code?	3
Insurance broker name	HILB ROGAL & HOBBS OF OHIO LLC

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	143
Insurance policy start date	2007-01-01
Insurance policy end date	2007-12-31
Total amount of commissions paid to insurance broker	USD $8,944
Total amount of fees paid to insurance company	USD $828
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,327
Amount paid for insurance broker fees	326
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	RICHARD HESLOP

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

246-6213-01

Policy instance

Insurance contract or identification number	246-6213-01
Number of Individuals Covered	228
Insurance policy start date	2007-02-01
Insurance policy end date	2007-05-31
Total amount of commissions paid to insurance broker	USD $1,356
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 $21,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,356
Insurance broker organization code?	3
Insurance broker name	HILB ROGAL & HOBBS

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

Policy contract number

E7158686

Policy instance

Insurance contract or identification number	E7158686
Number of Individuals Covered	150
Insurance policy start date	2006-01-01
Insurance policy end date	2006-12-31
Total amount of commissions paid to insurance broker	USD $10,517
Total amount of fees paid to insurance company	USD $639
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,635
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

59149

Policy instance

Insurance contract or identification number	59149
Number of Individuals Covered	32
Insurance policy start date	2006-01-01
Insurance policy end date	2006-12-31
Total amount of commissions paid to insurance broker	USD $3,778
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

246-6213-00

Policy instance

Insurance contract or identification number	246-6213-00
Number of Individuals Covered	215
Insurance policy start date	2005-02-01
Insurance policy end date	2006-01-31
Total amount of commissions paid to insurance broker	USD $4,150
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 $41,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	FARMERS AND MERCHANTS STATE BANK
Employer identification number (EIN):	344230390
NAIC Classification:	522120
NAIC Description:	Savings Institutions