401k Plan data: EMPLOYEE WELFARE BENEFIT PLAN plan

EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number	501

EMPLOYEE WELFARE BENEFIT 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

SCOTT PET PRODUCTS, INC. has sponsored the creation of one or more 401k plans.

Company Name: SCOTT PET PRODUCTS, INC.

Employer identification number (EIN): 351506935

NAIC Classification: 339900

Additional information about SCOTT PET PRODUCTS, INC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2015-08-17

Company Identification Number: 0802278219

Legal Registered Office Address: 1543 N US HIGHWAY 41

ROCKVILLE
United States of America (USA)
47872

More information about SCOTT PET PRODUCTS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01 JADE WARREN 2022-06-28
501 2020-01-01 SHAUNI BENNETT 2021-07-29
501 2019-01-01 SHAUNI BENNETT 2020-07-13
501 2018-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01 NANCY INMAN MICHAEL BASSETT 2016-07-27
501 2014-01-01 NANCY INMAN MICHAEL BASSETT 2015-07-27
501 2013-01-01 NANCY INMAN
501 2012-01-01 TRACEY LYONS
501 2011-01-01 TRACEY LYONS

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-01-01	JADE WARREN	2022-06-28
501	2020-01-01	SHAUNI BENNETT	2021-07-29
501	2019-01-01	SHAUNI BENNETT	2020-07-13
501	2018-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01	NANCY INMAN		MICHAEL BASSETT	2016-07-27
501	2014-01-01	NANCY INMAN		MICHAEL BASSETT	2015-07-27
501	2013-01-01	NANCY INMAN
501	2012-01-01	TRACEY LYONS
501	2011-01-01	TRACEY LYONS

Plan Statistics for EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2021: EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 134
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 139
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 139
2020: EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 134
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 134
2019: EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 140
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 140
2018: EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 128
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 128
2017: EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 120
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 114
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 114
2016: EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 120
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 120
2015: EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 118
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 118
2014: EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 115
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 115
2013: EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 104
Total of all active and inactive participants 2013-01-01 104
2012: EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 119
Total of all active and inactive participants 2012-01-01 119
2011: EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 124
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 124

Measure	Date	Value
2021: EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	134
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	139
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	139
2020: EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	134
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	134
2019: EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	140
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	140
2018: EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	128
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	128
2017: EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	120
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	114
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	114
2016: EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	120
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	120
2015: EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	118
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	118
2014: EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	115
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	115
2013: EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	104
Total of all active and inactive participants	2013-01-01	104
2012: EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	119
Total of all active and inactive participants	2012-01-01	119
2011: EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	124
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	124

Form 5500 Responses for EMPLOYEE WELFARE BENEFIT PLAN

2021: EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: EMPLOYEE WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: EMPLOYEE WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: EMPLOYEE WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

609937

Policy instance

Insurance contract or identification number	609937
Number of Individuals Covered	111
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $2,394
Total amount of fees paid to insurance company	USD $205
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,191
Amount paid for insurance broker fees	205
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98062661001

Policy instance

Insurance contract or identification number	98062661001
Number of Individuals Covered	125
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $826
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $697
Insurance broker organization code?	3

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

W11030

Policy instance

Insurance contract or identification number	W11030
Number of Individuals Covered	83
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $25,305
Total amount of fees paid to insurance company	USD $343
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $671,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,428
Amount paid for insurance broker fees	343
Insurance broker organization code?	3

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	3
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $142
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $1,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36
Insurance broker organization code?	3

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

Policy contract number

609938

Policy instance

Insurance contract or identification number	609938
Number of Individuals Covered	77
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $1,186
Total amount of fees paid to insurance company	USD $108
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,088
Amount paid for insurance broker fees	108
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

609308

Policy instance

Insurance contract or identification number	609308
Number of Individuals Covered	139
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $3,783
Total amount of fees paid to insurance company	USD $344
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,831
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	344
Insurance broker organization code?	3

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

Policy contract number

606910

Policy instance

Insurance contract or identification number	606910
Number of Individuals Covered	139
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $286
Total amount of fees paid to insurance company	USD $36
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $262
Amount paid for insurance broker fees	36
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

960933

Policy instance

Insurance contract or identification number	960933
Number of Individuals Covered	139
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $1,548
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $11,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,548
Insurance broker organization code?	3

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

Policy contract number

960933

Policy instance

Insurance contract or identification number	960933
Number of Individuals Covered	134
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $8,685
Total amount of fees paid to insurance company	USD $1,727
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS, DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $81,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,685
Amount paid for insurance broker fees	1727
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

W11030

Policy instance

Insurance contract or identification number	W11030
Number of Individuals Covered	80
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $23,246
Total amount of fees paid to insurance company	USD $1,309
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $618,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,246
Amount paid for insurance broker fees	1309
Insurance broker organization code?	3

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	4
Insurance policy start date	2019-11-01
Insurance policy end date	2020-10-31
Total amount of commissions paid to insurance broker	USD $194
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $2,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98062661001

Policy instance

Insurance contract or identification number	98062661001
Number of Individuals Covered	111
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $662
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $662
Insurance broker organization code?	3

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	5
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $221
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $2,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36
Insurance broker organization code?	3

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

W11030

Policy instance

Insurance contract or identification number	W11030
Number of Individuals Covered	61
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $18,415
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $511,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,415
Insurance broker organization code?	3

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

Policy contract number

960933

Policy instance

Insurance contract or identification number	960933
Number of Individuals Covered	140
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $6,751
Total amount of fees paid to insurance company	USD $1,179
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS, DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $63,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,751
Amount paid for insurance broker fees	1179
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98062661001

Policy instance

Insurance contract or identification number	98062661001
Number of Individuals Covered	101
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $579
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $579
Insurance broker organization code?	3

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

290936

Policy instance

Insurance contract or identification number	290936
Number of Individuals Covered	72
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $3,181
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,181
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

08745

Policy instance

Insurance contract or identification number	08745
Number of Individuals Covered	127
Insurance policy start date	2018-01-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $6,544
Total amount of fees paid to insurance company	USD $41
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $54,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,544
Insurance broker organization code?	3
Amount paid for insurance broker fees	41
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

0083876

Policy instance

Insurance contract or identification number	0083876
Number of Individuals Covered	56
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $19,850
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $514,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,703
Insurance broker organization code?	3

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	5
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $192
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $2,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33
Insurance broker organization code?	3

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

290936

Policy instance

Insurance contract or identification number	290936
Number of Individuals Covered	66
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $2,896
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,896
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98062661001

Policy instance

Insurance contract or identification number	98062661001
Number of Individuals Covered	90
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $554
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $325
Insurance broker organization code?	3

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

Policy contract number

0351506935-0000

Policy instance

Insurance contract or identification number	0351506935-0000
Number of Individuals Covered	128
Insurance policy start date	2018-12-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $781
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $458
Insurance broker organization code?	3

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

290936

Policy instance

Insurance contract or identification number	290936
Number of Individuals Covered	56
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $2,498
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,498
Insurance broker organization code?	3
Insurance broker name	MJ INSURANCE, INC.

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98062661001

Policy instance

Insurance contract or identification number	98062661001
Number of Individuals Covered	81
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $523
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $523
Insurance broker organization code?	3
Insurance broker name	MJ INSURANCE, INC.

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

08745

Policy instance

Insurance contract or identification number	08745
Number of Individuals Covered	114
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,608
Total amount of fees paid to insurance company	USD $37
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $98,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,608
Insurance broker organization code?	3
Amount paid for insurance broker fees	37
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

0083876

Policy instance

Insurance contract or identification number	0083876
Number of Individuals Covered	46
Insurance policy start date	2016-12-01
Insurance policy end date	2017-11-30
Total amount of commissions paid to insurance broker	USD $17,504
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $396,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,863
Insurance broker organization code?	3
Insurance broker name	IMASERV INC

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	5
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $208
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $2,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40
Insurance broker organization code?	3
Insurance broker name	JENNIFER L MITCHEN

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	10
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $1,427
Total amount of fees paid to insurance company	USD $187
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $6,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $770
Amount paid for insurance broker fees	118
Insurance broker organization code?	3
Insurance broker name	HARROLD/HUGHES INSURANCE

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

08745

Policy instance

Insurance contract or identification number	08745
Number of Individuals Covered	118
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,386
Total amount of fees paid to insurance company	USD $42
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 $87,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,386
Insurance broker organization code?	3
Amount paid for insurance broker fees	42
Insurance broker name	AXA ASSISTANCE, USA

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

0083876

Policy instance

Insurance contract or identification number	0083876
Number of Individuals Covered	40
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $18,390
Total amount of fees paid to insurance company	USD $252
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $331,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,893
Amount paid for insurance broker fees	252
Insurance broker organization code?	3
Insurance broker name	IMASERV INC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9806266

Policy instance

Insurance contract or identification number	9806266
Number of Individuals Covered	107
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $647
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $647
Insurance broker organization code?	3
Insurance broker name	MJ INSURANCE, INC.

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

2909361

Policy instance

Insurance contract or identification number	2909361
Number of Individuals Covered	72
Insurance policy start date	2014-12-01
Insurance policy end date	2015-11-30
Total amount of commissions paid to insurance broker	USD $3,246
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,246
Insurance broker organization code?	3
Insurance broker name	MJ INSURANCE, INC.

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

290936

Policy instance

Insurance contract or identification number	290936
Number of Individuals Covered	73
Insurance policy start date	2014-12-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $262
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 $2,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $262
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ASSURED PARTNERS OF INDIANA LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9806266

Policy instance

Insurance contract or identification number	9806266
Number of Individuals Covered	110
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $624
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 $6,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $354
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MJ INSURANCE, INC.

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

0083876

Policy instance

Insurance contract or identification number	0083876
Number of Individuals Covered	35
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $8,562
Total amount of fees paid to insurance company	USD $193
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 $309,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,488
Amount paid for insurance broker fees	193
Insurance broker organization code?	3
Insurance broker name	IMASERV INC

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	34
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $2,316
Total amount of fees paid to insurance company	USD $63
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	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $8,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,372
Amount paid for insurance broker fees	45
Insurance broker organization code?	3
Insurance broker name	HARROLD/HUGHES INSURANCE

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

Policy contract number

00328472

Policy instance

Insurance contract or identification number	00328472
Number of Individuals Covered	67
Insurance policy start date	2014-01-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $3,924
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 $28,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,748
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	HORIZON PLANNING GROUP

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

08745

Policy instance

Insurance contract or identification number	08745
Number of Individuals Covered	115
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,890
Total amount of fees paid to insurance company	USD $42
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 $77,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,244
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	AXA ASSISTANCE, USA

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

0083876

Policy instance

Insurance contract or identification number	0083876
Number of Individuals Covered	35
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $375
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 $298,940
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	375
Insurance broker organization code?	3
Insurance broker name	TOBIAS INSURANCE GROUP

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

08745

Policy instance

Insurance contract or identification number	08745
Number of Individuals Covered	103
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,816
Total amount of fees paid to insurance company	USD $34
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 $63,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,816
Insurance broker organization code?	3
Amount paid for insurance broker fees	34
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	27
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $2,275
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	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $9,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,513
Insurance broker organization code?	3
Insurance broker name	HARROLD/HUGHES INSURANCE

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9806266

Policy instance

Insurance contract or identification number	9806266
Number of Individuals Covered	104
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $684
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 $6,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $684
Insurance broker organization code?	3
Insurance broker name	ASSURED PARTNERS ON INDIANA

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

Policy contract number

00328472

Policy instance

Insurance contract or identification number	00328472
Number of Individuals Covered	58
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,229
Total amount of fees paid to insurance company	USD $1,202
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 $29,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,207
Amount paid for insurance broker fees	1202
Insurance broker organization code?	3
Insurance broker name	HORIZON PLANNING GROUP

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

Policy contract number

00328472

Policy instance

Insurance contract or identification number	00328472
Number of Individuals Covered	61
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,274
Total amount of fees paid to insurance company	USD $1,647
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 $30,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,251
Amount paid for insurance broker fees	1647
Insurance broker organization code?	3
Insurance broker name	HORIZON PLANNING GROUP

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

Policy contract number

WK557

Policy instance

Insurance contract or identification number	WK557
Number of Individuals Covered	7
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,063
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	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $5,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $823
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BARBARA ANN MCNAUGHTON

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	29
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,186
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	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $7,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $576
Insurance broker organization code?	3
Insurance broker name	HARROLD/HUGHES INSURANCE

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

08745

Policy instance

Insurance contract or identification number	08745
Number of Individuals Covered	101
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,666
Total amount of fees paid to insurance company	USD $38
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 $62,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,666
Insurance broker organization code?	3
Amount paid for insurance broker fees	38
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

0083876

Policy instance

Insurance contract or identification number	0083876
Number of Individuals Covered	28
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,109
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 $231,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,109
Insurance broker organization code?	3
Insurance broker name	TOBIAS INSURANCE GROUP

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9806266

Policy instance

Insurance contract or identification number	9806266
Number of Individuals Covered	119
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $702
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 $6,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $702
Insurance broker organization code?	3
Insurance broker name	TOBIAS INSURANCE GROUP

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9806266

Policy instance

Insurance contract or identification number	9806266
Number of Individuals Covered	121
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $711
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 $7,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

854300G

Policy instance

Insurance contract or identification number	854300G
Number of Individuals Covered	124
Insurance policy start date	2010-09-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $1,401
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00328472

Policy instance

Insurance contract or identification number	00328472
Number of Individuals Covered	65
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,284
Total amount of fees paid to insurance company	USD $1,933
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
Vision Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

00083786

Policy instance

Insurance contract or identification number	00083786
Number of Individuals Covered	30
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,598
Total amount of fees paid to insurance company	USD $98
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 $227,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	20
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,561
Total amount of fees paid to insurance company	USD $211
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	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $8,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

WK557

Policy instance

Insurance contract or identification number	WK557
Number of Individuals Covered	19
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,830
Total amount of fees paid to insurance company	USD $36
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	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $6,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

08745

Policy instance

Insurance contract or identification number	08745
Number of Individuals Covered	105
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,147
Total amount of fees paid to insurance company	USD $82
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $62,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9806266

Policy instance

Insurance contract or identification number	9806266
Number of Individuals Covered	124
Insurance policy start date	2010-12-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,142
Total amount of fees paid to insurance company	USD $82
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 $4,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

854300G

Policy instance

Insurance contract or identification number	854300G
Number of Individuals Covered	119
Insurance policy start date	2009-09-01
Insurance policy end date	2010-08-31
Total amount of commissions paid to insurance broker	USD $5,444
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $32,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

00083786

Policy instance

Insurance contract or identification number	00083786
Number of Individuals Covered	30
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $10,498
Total amount of fees paid to insurance company	USD $374
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 $224,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

72635

Policy instance

Insurance contract or identification number	72635
Number of Individuals Covered	21
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $470
Total amount of fees paid to insurance company	USD $30
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	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $4,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

WK557

Policy instance

Insurance contract or identification number	WK557
Number of Individuals Covered	15
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,142
Total amount of fees paid to insurance company	USD $82
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	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $4,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00 328472

Policy instance

Insurance contract or identification number	00 328472
Number of Individuals Covered	72
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,149
Total amount of fees paid to insurance company	USD $1,021
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SCOTT PET PRODUCTS, INC.
Employer identification number (EIN):	351506935
NAIC Classification:	339900

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2015-08-17
Company Identification Number:	0802278219
Legal Registered Office Address:	1543 N US HIGHWAY 41 ROCKVILLE United States of America (USA) 47872