401k Plan data: GENERAL SHEET METAL WORKS, INC. plan

GENERAL SHEET METAL WORKS, INC. 401k Plan overview

Plan Name	GENERAL SHEET METAL WORKS, INC.
Plan identification number	501

GENERAL SHEET METAL WORKS, INC. 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

GENERAL SHEET METAL WORKS, INC. has sponsored the creation of one or more 401k plans.

Company Name: GENERAL SHEET METAL WORKS, INC.

Employer identification number (EIN): 350333580

NAIC Classification: 332110

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GENERAL SHEET METAL WORKS, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-06-01 JOHN M RYAL 2023-12-20 JOHN M RYAL 2023-12-20
501 2021-06-01 JOHN M RYAL 2023-03-10 JOHN M RYAL 2023-03-10
501 2020-06-01 JOHN M RYAL 2022-03-11 JOHN M RYAL 2022-03-11
501 2019-06-01 JOHN M RYAL 2021-03-12
501 2018-06-01 JOHN M RYAL 2020-01-14
501 2017-06-01
501 2016-06-01
501 2015-06-01
501 2014-06-01
501 2013-06-01
501 2012-06-01 JOHN RYAL

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-06-01	JOHN M RYAL	2023-12-20	JOHN M RYAL	2023-12-20
501	2021-06-01	JOHN M RYAL	2023-03-10	JOHN M RYAL	2023-03-10
501	2020-06-01	JOHN M RYAL	2022-03-11	JOHN M RYAL	2022-03-11
501	2019-06-01	JOHN M RYAL	2021-03-12
501	2018-06-01	JOHN M RYAL	2020-01-14
501	2017-06-01
501	2016-06-01
501	2015-06-01
501	2014-06-01
501	2013-06-01
501	2012-06-01	JOHN RYAL

Plan Statistics for GENERAL SHEET METAL WORKS, INC.

401k plan membership statisitcs for GENERAL SHEET METAL WORKS, INC.

Measure Date Value
2022: GENERAL SHEET METAL WORKS, INC. 2022 401k membership
Total participants, beginning-of-year 2022-06-01 331
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 298
Number of retired or separated participants receiving benefits 2022-06-01 0
Number of other retired or separated participants entitled to future benefits 2022-06-01 0
Total of all active and inactive participants 2022-06-01 298
2021: GENERAL SHEET METAL WORKS, INC. 2021 401k membership
Total participants, beginning-of-year 2021-06-01 332
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 331
Number of retired or separated participants receiving benefits 2021-06-01 0
Number of other retired or separated participants entitled to future benefits 2021-06-01 0
Total of all active and inactive participants 2021-06-01 331
2020: GENERAL SHEET METAL WORKS, INC. 2020 401k membership
Total participants, beginning-of-year 2020-06-01 286
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 331
Number of retired or separated participants receiving benefits 2020-06-01 1
Number of other retired or separated participants entitled to future benefits 2020-06-01 0
Total of all active and inactive participants 2020-06-01 332
2019: GENERAL SHEET METAL WORKS, INC. 2019 401k membership
Total participants, beginning-of-year 2019-06-01 240
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 285
Number of retired or separated participants receiving benefits 2019-06-01 1
Number of other retired or separated participants entitled to future benefits 2019-06-01 0
Total of all active and inactive participants 2019-06-01 286
2018: GENERAL SHEET METAL WORKS, INC. 2018 401k membership
Total participants, beginning-of-year 2018-06-01 214
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 239
Number of retired or separated participants receiving benefits 2018-06-01 1
Number of other retired or separated participants entitled to future benefits 2018-06-01 0
Total of all active and inactive participants 2018-06-01 240
2017: GENERAL SHEET METAL WORKS, INC. 2017 401k membership
Total participants, beginning-of-year 2017-06-01 207
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 214
Number of retired or separated participants receiving benefits 2017-06-01 0
Number of other retired or separated participants entitled to future benefits 2017-06-01 0
Total of all active and inactive participants 2017-06-01 214
2016: GENERAL SHEET METAL WORKS, INC. 2016 401k membership
Total participants, beginning-of-year 2016-06-01 281
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 201
Number of retired or separated participants receiving benefits 2016-06-01 3
Number of other retired or separated participants entitled to future benefits 2016-06-01 3
Total of all active and inactive participants 2016-06-01 207
2015: GENERAL SHEET METAL WORKS, INC. 2015 401k membership
Total participants, beginning-of-year 2015-06-01 209
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 281
Total of all active and inactive participants 2015-06-01 281
2014: GENERAL SHEET METAL WORKS, INC. 2014 401k membership
Total participants, beginning-of-year 2014-06-01 209
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 209
Number of retired or separated participants receiving benefits 2014-06-01 0
Number of other retired or separated participants entitled to future benefits 2014-06-01 0
Total of all active and inactive participants 2014-06-01 209
2013: GENERAL SHEET METAL WORKS, INC. 2013 401k membership
Total participants, beginning-of-year 2013-06-01 175
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 206
Number of retired or separated participants receiving benefits 2013-06-01 0
Number of other retired or separated participants entitled to future benefits 2013-06-01 3
Total of all active and inactive participants 2013-06-01 209
2012: GENERAL SHEET METAL WORKS, INC. 2012 401k membership
Total participants, beginning-of-year 2012-06-01 143
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 175
Total of all active and inactive participants 2012-06-01 175

Measure	Date	Value
2022: GENERAL SHEET METAL WORKS, INC. 2022 401k membership
Total participants, beginning-of-year	2022-06-01	331
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	298
Number of retired or separated participants receiving benefits	2022-06-01	0
Number of other retired or separated participants entitled to future benefits	2022-06-01	0
Total of all active and inactive participants	2022-06-01	298
2021: GENERAL SHEET METAL WORKS, INC. 2021 401k membership
Total participants, beginning-of-year	2021-06-01	332
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	331
Number of retired or separated participants receiving benefits	2021-06-01	0
Number of other retired or separated participants entitled to future benefits	2021-06-01	0
Total of all active and inactive participants	2021-06-01	331
2020: GENERAL SHEET METAL WORKS, INC. 2020 401k membership
Total participants, beginning-of-year	2020-06-01	286
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	331
Number of retired or separated participants receiving benefits	2020-06-01	1
Number of other retired or separated participants entitled to future benefits	2020-06-01	0
Total of all active and inactive participants	2020-06-01	332
2019: GENERAL SHEET METAL WORKS, INC. 2019 401k membership
Total participants, beginning-of-year	2019-06-01	240
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	285
Number of retired or separated participants receiving benefits	2019-06-01	1
Number of other retired or separated participants entitled to future benefits	2019-06-01	0
Total of all active and inactive participants	2019-06-01	286
2018: GENERAL SHEET METAL WORKS, INC. 2018 401k membership
Total participants, beginning-of-year	2018-06-01	214
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	239
Number of retired or separated participants receiving benefits	2018-06-01	1
Number of other retired or separated participants entitled to future benefits	2018-06-01	0
Total of all active and inactive participants	2018-06-01	240
2017: GENERAL SHEET METAL WORKS, INC. 2017 401k membership
Total participants, beginning-of-year	2017-06-01	207
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	214
Number of retired or separated participants receiving benefits	2017-06-01	0
Number of other retired or separated participants entitled to future benefits	2017-06-01	0
Total of all active and inactive participants	2017-06-01	214
2016: GENERAL SHEET METAL WORKS, INC. 2016 401k membership
Total participants, beginning-of-year	2016-06-01	281
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	201
Number of retired or separated participants receiving benefits	2016-06-01	3
Number of other retired or separated participants entitled to future benefits	2016-06-01	3
Total of all active and inactive participants	2016-06-01	207
2015: GENERAL SHEET METAL WORKS, INC. 2015 401k membership
Total participants, beginning-of-year	2015-06-01	209
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	281
Total of all active and inactive participants	2015-06-01	281
2014: GENERAL SHEET METAL WORKS, INC. 2014 401k membership
Total participants, beginning-of-year	2014-06-01	209
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	209
Number of retired or separated participants receiving benefits	2014-06-01	0
Number of other retired or separated participants entitled to future benefits	2014-06-01	0
Total of all active and inactive participants	2014-06-01	209
2013: GENERAL SHEET METAL WORKS, INC. 2013 401k membership
Total participants, beginning-of-year	2013-06-01	175
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	206
Number of retired or separated participants receiving benefits	2013-06-01	0
Number of other retired or separated participants entitled to future benefits	2013-06-01	3
Total of all active and inactive participants	2013-06-01	209
2012: GENERAL SHEET METAL WORKS, INC. 2012 401k membership
Total participants, beginning-of-year	2012-06-01	143
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	175
Total of all active and inactive participants	2012-06-01	175

Form 5500 Responses for GENERAL SHEET METAL WORKS, INC.

2022: GENERAL SHEET METAL WORKS, INC. 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: GENERAL SHEET METAL WORKS, INC. 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: GENERAL SHEET METAL WORKS, INC. 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: GENERAL SHEET METAL WORKS, INC. 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: GENERAL SHEET METAL WORKS, INC. 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: GENERAL SHEET METAL WORKS, INC. 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: GENERAL SHEET METAL WORKS, INC. 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: GENERAL SHEET METAL WORKS, INC. 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: GENERAL SHEET METAL WORKS, INC. 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: GENERAL SHEET METAL WORKS, INC. 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: GENERAL SHEET METAL WORKS, INC. 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SHD963340

Policy instance

Insurance contract or identification number	SHD963340
Number of Individuals Covered	256
Insurance policy start date	2022-01-01
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 $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33
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

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	215
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $1,453
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,453
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX968997

Policy instance

Insurance contract or identification number	FLX968997
Number of Individuals Covered	258
Insurance policy start date	2022-01-01
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 $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX968998

Policy instance

Insurance contract or identification number	FLX968998
Number of Individuals Covered	293
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,633
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,633
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK966014

Policy instance

Insurance contract or identification number	LK966014
Number of Individuals Covered	195
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $10,258
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,258
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970458

Policy instance

Insurance contract or identification number	OK970458
Number of Individuals Covered	258
Insurance policy start date	2022-01-01
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 $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970459

Policy instance

Insurance contract or identification number	OK970459
Number of Individuals Covered	293
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,406
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,406
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00626128

Policy instance

Insurance contract or identification number	00626128
Number of Individuals Covered	443
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $49,962
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $716,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,962
Insurance broker organization code?	3

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

Policy contract number

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	230
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $1,283
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,283
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX968997

Policy instance

Insurance contract or identification number	FLX968997
Number of Individuals Covered	282
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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
Welfare Benefit Premiums Paid to Carrier	USD $13,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX968998

Policy instance

Insurance contract or identification number	FLX968998
Number of Individuals Covered	331
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,584
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,584
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK966014

Policy instance

Insurance contract or identification number	LK966014
Number of Individuals Covered	221
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,475
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,475
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970458

Policy instance

Insurance contract or identification number	OK970458
Number of Individuals Covered	282
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970459

Policy instance

Insurance contract or identification number	OK970459
Number of Individuals Covered	331
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,429
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,429
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00626128

Policy instance

Insurance contract or identification number	00626128
Number of Individuals Covered	264
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $52,619
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $719,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,619
Insurance broker organization code?	3

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

Policy contract number

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	234
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,327
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,327
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX968997

Policy instance

Insurance contract or identification number	FLX968997
Number of Individuals Covered	283
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 $641
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	641
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX968998

Policy instance

Insurance contract or identification number	FLX968998
Number of Individuals Covered	331
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,083
Total amount of fees paid to insurance company	USD $1,883
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,083
Amount paid for insurance broker fees	1883
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK966014

Policy instance

Insurance contract or identification number	LK966014
Number of Individuals Covered	231
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,280
Total amount of fees paid to insurance company	USD $2,473
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,280
Amount paid for insurance broker fees	2473
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970458

Policy instance

Insurance contract or identification number	OK970458
Number of Individuals Covered	283
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 $148
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	148
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970459

Policy instance

Insurance contract or identification number	OK970459
Number of Individuals Covered	331
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,032
Total amount of fees paid to insurance company	USD $247
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,032
Amount paid for insurance broker fees	247
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00626128

Policy instance

Insurance contract or identification number	00626128
Number of Individuals Covered	267
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $49,121
Total amount of fees paid to insurance company	USD $9,711
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $649,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,121
Amount paid for insurance broker fees	9711
Insurance broker organization code?	3

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

Policy contract number

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	245
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,373
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,373
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX968998

Policy instance

Insurance contract or identification number	FLX968998
Number of Individuals Covered	269
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $2,557
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,557
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX968997

Policy instance

Insurance contract or identification number	FLX968997
Number of Individuals Covered	226
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
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
Welfare Benefit Premiums Paid to Carrier	USD $4,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

LK966014

Policy instance

Insurance contract or identification number	LK966014
Number of Individuals Covered	192
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $2,645
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,645
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970458

Policy instance

Insurance contract or identification number	OK970458
Number of Individuals Covered	226
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK970459

Policy instance

Insurance contract or identification number	OK970459
Number of Individuals Covered	269
Insurance policy start date	2019-06-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $364
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $364
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00626128

Policy instance

Insurance contract or identification number	00626128
Number of Individuals Covered	285
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $28,265
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $320,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,265
Insurance broker organization code?	3

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

Policy contract number

000010130101

Policy instance

Insurance contract or identification number	000010130101
Number of Individuals Covered	288
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $110
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $24,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	110
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

417007410976

Policy instance

Insurance contract or identification number	417007410976
Number of Individuals Covered	249
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
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 $683,915
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

417008410976

Policy instance

Insurance contract or identification number	417008410976
Number of Individuals Covered	249
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $21,583
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

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	196
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $1,245
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,245
Insurance broker organization code?	3

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

Policy contract number

000010130102

Policy instance

Insurance contract or identification number	000010130102
Number of Individuals Covered	179
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $8,699
Total amount of fees paid to insurance company	USD $248
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,699
Amount paid for insurance broker fees	248
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

000400001000011

Policy instance

Insurance contract or identification number	000400001000011
Number of Individuals Covered	133
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $6,904
Total amount of fees paid to insurance company	USD $150
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,904
Amount paid for insurance broker fees	150
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6C

Policy instance

Insurance contract or identification number	33001201GS6C
Number of Individuals Covered	1
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
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
Welfare Benefit Premiums Paid to Carrier	USD $42
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: 65675 )

Policy contract number

000400001000011

Policy instance

Insurance contract or identification number	000400001000011
Number of Individuals Covered	102
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $5,673
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,673
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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

Policy contract number

000010130101

Policy instance

Insurance contract or identification number	000010130101
Number of Individuals Covered	245
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

417007410976

Policy instance

Insurance contract or identification number	417007410976
Number of Individuals Covered	219
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
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 $607,031
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

417008410976

Policy instance

Insurance contract or identification number	417008410976
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $19,790
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

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	176
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $1,163
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,163
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS2

Policy instance

Insurance contract or identification number	33001201GS2
Number of Individuals Covered	45
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
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
Welfare Benefit Premiums Paid to Carrier	USD $1,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6

Policy instance

Insurance contract or identification number	33001201GS6
Number of Individuals Covered	156
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
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
Welfare Benefit Premiums Paid to Carrier	USD $5,625
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: 65675 )

Policy contract number

000010130102

Policy instance

Insurance contract or identification number	000010130102
Number of Individuals Covered	158
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $7,494
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,494
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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

Policy contract number

000010130101

Policy instance

Insurance contract or identification number	000010130101
Number of Individuals Covered	281
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $267
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	267
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )

Policy contract number

417006410976

Policy instance

Insurance contract or identification number	417006410976
Number of Individuals Covered	266
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
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 $434,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

US FIRE (National Association of Insurance Commissioners NAIC id number: 21113 )

Policy contract number

417005410976

Policy instance

Insurance contract or identification number	417005410976
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $28,282
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: 53031 )

Policy contract number

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	205
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $1,140
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,140
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS2

Policy instance

Insurance contract or identification number	33001201GS2
Number of Individuals Covered	46
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
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
Welfare Benefit Premiums Paid to Carrier	USD $1,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6

Policy instance

Insurance contract or identification number	33001201GS6
Number of Individuals Covered	202
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
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
Welfare Benefit Premiums Paid to Carrier	USD $6,279
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: 65675 )

Policy contract number

000010130102

Policy instance

Insurance contract or identification number	000010130102
Number of Individuals Covered	198
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $6,953
Total amount of fees paid to insurance company	USD $486
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	THE HORTON GROUP

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6C

Policy instance

Insurance contract or identification number	33001201GS6C
Number of Individuals Covered	0
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
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
Welfare Benefit Premiums Paid to Carrier	USD $15
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: 65675 )

Policy contract number

000010130101

Policy instance

Insurance contract or identification number	000010130101
Number of Individuals Covered	227
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $377
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	377
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417004410976

Policy instance

Insurance contract or identification number	417004410976
Number of Individuals Covered	218
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $575,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

US FIRE (National Association of Insurance Commissioners NAIC id number: 21113 )

Policy contract number

417005410976

Policy instance

Insurance contract or identification number	417005410976
Number of Individuals Covered	0
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $24,327
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: 52050 )

Policy contract number

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	154
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,044
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,044
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS2

Policy instance

Insurance contract or identification number	33001201GS2
Number of Individuals Covered	34
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6

Policy instance

Insurance contract or identification number	33001201GS6
Number of Individuals Covered	157
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6C

Policy instance

Insurance contract or identification number	33001201GS6C
Number of Individuals Covered	1
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6C

Policy instance

Insurance contract or identification number	33001201GS6C
Number of Individuals Covered	0
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4
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: 65675 )

Policy contract number

000010130101

Policy instance

Insurance contract or identification number	000010130101
Number of Individuals Covered	206
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $511
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	511
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417004410976

Policy instance

Insurance contract or identification number	417004410976
Number of Individuals Covered	186
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $429,019
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: 52050 )

Policy contract number

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	131
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $901
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $901
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS2

Policy instance

Insurance contract or identification number	33001201GS2
Number of Individuals Covered	32
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6

Policy instance

Insurance contract or identification number	33001201GS6
Number of Individuals Covered	0
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS6

Policy instance

Insurance contract or identification number	33001201GS6
Number of Individuals Covered	113
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

417003410976

Policy instance

Insurance contract or identification number	417003410976
Number of Individuals Covered	156
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $614,860
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: 65675 )

Policy contract number

000010130102000

Policy instance

Insurance contract or identification number	000010130102000
Number of Individuals Covered	94
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $2,454
Total amount of fees paid to insurance company	USD $606
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 $16,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,454
Amount paid for insurance broker fees	606
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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

Policy contract number

000101301010

Policy instance

Insurance contract or identification number	000101301010
Number of Individuals Covered	175
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $376
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	376
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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

Policy contract number

000400001000118

Policy instance

Insurance contract or identification number	000400001000118
Number of Individuals Covered	108
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $3,651
Total amount of fees paid to insurance company	USD $687
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 $18,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,651
Amount paid for insurance broker fees	687
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )

Policy contract number

33001201GS2

Policy instance

Insurance contract or identification number	33001201GS2
Number of Individuals Covered	88
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $0
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $968
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: 52050 )

Policy contract number

30033342

Policy instance

Insurance contract or identification number	30033342
Number of Individuals Covered	98
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $825
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	825
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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Company Name:	GENERAL SHEET METAL WORKS, INC.
Employer identification number (EIN):	350333580
NAIC Classification:	332110