ADA S. MCKINLEY COMMUNITY SERVICES, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN
401k plan membership statisitcs for ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN
| Measure | Date | Value |
|---|
| 2017 : ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN 2017 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2017-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $111,150 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $48,018 |
| Total income from all sources (including contributions) | 2017-12-31 | $963,870 |
| Total loss/gain on sale of assets | 2017-12-31 | $0 |
| Total of all expenses incurred | 2017-12-31 | $940,574 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $758,419 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $923,364 |
| Value of total assets at end of year | 2017-12-31 | $571,400 |
| Value of total assets at beginning of year | 2017-12-31 | $484,972 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $182,155 |
| Total interest from all sources | 2017-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-12-31 | $8,966 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2017-12-31 | $8,966 |
| Administrative expenses professional fees incurred | 2017-12-31 | $33,265 |
| Was this plan covered by a fidelity bond | 2017-12-31 | Yes |
| Value of fidelity bond cover | 2017-12-31 | $500,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2017-12-31 | $7,500 |
| Assets. Other investments not covered elsewhere at beginning of year | 2017-12-31 | $98 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-12-31 | $5,044 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-12-31 | $0 |
| Administrative expenses (other) incurred | 2017-12-31 | $43,462 |
| Liabilities. Value of operating payables at end of year | 2017-12-31 | $102,295 |
| Liabilities. Value of operating payables at beginning of year | 2017-12-31 | $23,716 |
| Total non interest bearing cash at end of year | 2017-12-31 | $2,952 |
| Total non interest bearing cash at beginning of year | 2017-12-31 | $1,821 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $23,296 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $460,250 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $436,954 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Investment advisory and management fees | 2017-12-31 | $3,538 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2017-12-31 | $446,364 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2017-12-31 | $408,078 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2017-12-31 | $3,127 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2017-12-31 | $4,606 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2017-12-31 | $4,606 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $735,384 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2017-12-31 | $31,540 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $923,364 |
| Employer contributions (assets) at end of year | 2017-12-31 | $106,413 |
| Employer contributions (assets) at beginning of year | 2017-12-31 | $70,369 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-12-31 | $23,035 |
| Contract administrator fees | 2017-12-31 | $101,890 |
| Liabilities. Value of benefit claims payable at end of year | 2017-12-31 | $8,855 |
| Liabilities. Value of benefit claims payable at beginning of year | 2017-12-31 | $24,302 |
| Did the plan have assets held for investment | 2017-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Unqualified |
| Accountancy firm name | 2017-12-31 | INEICH & COMPANY, LLP |
| Accountancy firm EIN | 2017-12-31 | 562552172 |
| 2016 : ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN 2016 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2016-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $48,018 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $63,216 |
| Total income from all sources (including contributions) | 2016-12-31 | $989,952 |
| Total loss/gain on sale of assets | 2016-12-31 | $0 |
| Total of all expenses incurred | 2016-12-31 | $1,002,502 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $818,303 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $967,819 |
| Value of total assets at end of year | 2016-12-31 | $484,972 |
| Value of total assets at beginning of year | 2016-12-31 | $512,720 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $184,199 |
| Total interest from all sources | 2016-12-31 | $1 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-12-31 | $13,035 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2016-12-31 | $13,035 |
| Administrative expenses professional fees incurred | 2016-12-31 | $27,517 |
| Was this plan covered by a fidelity bond | 2016-12-31 | Yes |
| Value of fidelity bond cover | 2016-12-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2016-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2016-12-31 | $98 |
| Assets. Other investments not covered elsewhere at beginning of year | 2016-12-31 | $7,500 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-12-31 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-12-31 | $31,036 |
| Administrative expenses (other) incurred | 2016-12-31 | $52,234 |
| Liabilities. Value of operating payables at end of year | 2016-12-31 | $23,716 |
| Liabilities. Value of operating payables at beginning of year | 2016-12-31 | $61,172 |
| Total non interest bearing cash at end of year | 2016-12-31 | $1,821 |
| Total non interest bearing cash at beginning of year | 2016-12-31 | $7,952 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $-12,550 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $436,954 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $449,504 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Investment advisory and management fees | 2016-12-31 | $4,074 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2016-12-31 | $408,078 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2016-12-31 | $390,522 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2016-12-31 | $4,606 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2016-12-31 | $4,018 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2016-12-31 | $4,018 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2016-12-31 | $1 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $795,240 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2016-12-31 | $9,097 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Contributions received in cash from employer | 2016-12-31 | $967,819 |
| Employer contributions (assets) at end of year | 2016-12-31 | $70,369 |
| Employer contributions (assets) at beginning of year | 2016-12-31 | $71,692 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-12-31 | $23,063 |
| Contract administrator fees | 2016-12-31 | $100,374 |
| Liabilities. Value of benefit claims payable at end of year | 2016-12-31 | $24,302 |
| Liabilities. Value of benefit claims payable at beginning of year | 2016-12-31 | $2,044 |
| Did the plan have assets held for investment | 2016-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2016-12-31 | Unqualified |
| Accountancy firm name | 2016-12-31 | INEICH & COMPANY, LLP |
| Accountancy firm EIN | 2016-12-31 | 562552172 |
| 2015 : ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $63,216 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $42,635 |
| Total income from all sources (including contributions) | 2015-12-31 | $972,200 |
| Total loss/gain on sale of assets | 2015-12-31 | $0 |
| Total of all expenses incurred | 2015-12-31 | $999,260 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $815,017 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $975,820 |
| Value of total assets at end of year | 2015-12-31 | $512,720 |
| Value of total assets at beginning of year | 2015-12-31 | $519,199 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $184,243 |
| Total interest from all sources | 2015-12-31 | $17 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-12-31 | $16,451 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2015-12-31 | $16,451 |
| Administrative expenses professional fees incurred | 2015-12-31 | $27,078 |
| Was this plan covered by a fidelity bond | 2015-12-31 | Yes |
| Value of fidelity bond cover | 2015-12-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2015-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2015-12-31 | $7,500 |
| Assets. Other investments not covered elsewhere at beginning of year | 2015-12-31 | $15,000 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2015-12-31 | $31,036 |
| Administrative expenses (other) incurred | 2015-12-31 | $48,645 |
| Liabilities. Value of operating payables at end of year | 2015-12-31 | $61,172 |
| Liabilities. Value of operating payables at beginning of year | 2015-12-31 | $35,566 |
| Total non interest bearing cash at end of year | 2015-12-31 | $7,952 |
| Total non interest bearing cash at beginning of year | 2015-12-31 | $68,687 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $-27,060 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $449,504 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $476,564 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Investment advisory and management fees | 2015-12-31 | $4,014 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2015-12-31 | $390,522 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2015-12-31 | $397,164 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2015-12-31 | $4,018 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2015-12-31 | $5,033 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2015-12-31 | $5,033 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2015-12-31 | $17 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $807,585 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2015-12-31 | $-20,088 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $975,820 |
| Employer contributions (assets) at end of year | 2015-12-31 | $71,692 |
| Employer contributions (assets) at beginning of year | 2015-12-31 | $33,315 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-12-31 | $7,432 |
| Contract administrator fees | 2015-12-31 | $104,506 |
| Liabilities. Value of benefit claims payable at end of year | 2015-12-31 | $2,044 |
| Liabilities. Value of benefit claims payable at beginning of year | 2015-12-31 | $7,069 |
| Did the plan have assets held for investment | 2015-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Unqualified |
| Accountancy firm name | 2015-12-31 | INEICH & COMPANY, LLP |
| Accountancy firm EIN | 2015-12-31 | 562552172 |
| 2014 : ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $42,635 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $14,508 |
| Total income from all sources (including contributions) | 2014-12-31 | $1,032,308 |
| Total loss/gain on sale of assets | 2014-12-31 | $0 |
| Total of all expenses incurred | 2014-12-31 | $1,028,325 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-12-31 | $858,769 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-12-31 | $1,015,078 |
| Value of total assets at end of year | 2014-12-31 | $519,199 |
| Value of total assets at beginning of year | 2014-12-31 | $487,089 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-12-31 | $169,556 |
| Total interest from all sources | 2014-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-12-31 | $10,698 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2014-12-31 | $10,698 |
| Administrative expenses professional fees incurred | 2014-12-31 | $27,959 |
| Was this plan covered by a fidelity bond | 2014-12-31 | Yes |
| Value of fidelity bond cover | 2014-12-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2014-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2014-12-31 | $15,000 |
| Administrative expenses (other) incurred | 2014-12-31 | $33,246 |
| Liabilities. Value of operating payables at end of year | 2014-12-31 | $35,566 |
| Liabilities. Value of operating payables at beginning of year | 2014-12-31 | $14,508 |
| Total non interest bearing cash at end of year | 2014-12-31 | $68,687 |
| Total non interest bearing cash at beginning of year | 2014-12-31 | $69,169 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Value of net income/loss | 2014-12-31 | $3,983 |
| Value of net assets at end of year (total assets less liabilities) | 2014-12-31 | $476,564 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-12-31 | $472,581 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-12-31 | No |
| Investment advisory and management fees | 2014-12-31 | $4,001 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2014-12-31 | $397,164 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2014-12-31 | $384,267 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2014-12-31 | $5,033 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2014-12-31 | $4,665 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2014-12-31 | $4,665 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-12-31 | $849,896 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2014-12-31 | $6,532 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-12-31 | No |
| Contributions received in cash from employer | 2014-12-31 | $1,015,078 |
| Employer contributions (assets) at end of year | 2014-12-31 | $33,315 |
| Employer contributions (assets) at beginning of year | 2014-12-31 | $28,988 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-12-31 | $8,873 |
| Contract administrator fees | 2014-12-31 | $104,350 |
| Liabilities. Value of benefit claims payable at end of year | 2014-12-31 | $7,069 |
| Did the plan have assets held for investment | 2014-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-12-31 | Unqualified |
| Accountancy firm name | 2014-12-31 | INEICH & COMPANY LLP |
| Accountancy firm EIN | 2014-12-31 | 562552172 |
| 2013 : ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $14,508 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $2,872 |
| Total income from all sources (including contributions) | 2013-12-31 | $995,877 |
| Total loss/gain on sale of assets | 2013-12-31 | $0 |
| Total of all expenses incurred | 2013-12-31 | $992,800 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-12-31 | $865,122 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-12-31 | $961,857 |
| Value of total assets at end of year | 2013-12-31 | $487,089 |
| Value of total assets at beginning of year | 2013-12-31 | $472,376 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-12-31 | $127,678 |
| Total interest from all sources | 2013-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-12-31 | $9,352 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2013-12-31 | $9,352 |
| Administrative expenses professional fees incurred | 2013-12-31 | $1,952 |
| Was this plan covered by a fidelity bond | 2013-12-31 | Yes |
| Value of fidelity bond cover | 2013-12-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2013-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-12-31 | No |
| Administrative expenses (other) incurred | 2013-12-31 | $18,502 |
| Liabilities. Value of operating payables at end of year | 2013-12-31 | $14,508 |
| Liabilities. Value of operating payables at beginning of year | 2013-12-31 | $2,872 |
| Total non interest bearing cash at end of year | 2013-12-31 | $69,169 |
| Total non interest bearing cash at beginning of year | 2013-12-31 | $83,230 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Value of net income/loss | 2013-12-31 | $3,077 |
| Value of net assets at end of year (total assets less liabilities) | 2013-12-31 | $472,581 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-12-31 | $469,504 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-12-31 | No |
| Investment advisory and management fees | 2013-12-31 | $4,652 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2013-12-31 | $384,267 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2013-12-31 | $353,756 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2013-12-31 | $4,665 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2013-12-31 | $5,136 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2013-12-31 | $5,136 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-12-31 | $862,062 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2013-12-31 | $24,668 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-12-31 | No |
| Contributions received in cash from employer | 2013-12-31 | $961,857 |
| Employer contributions (assets) at end of year | 2013-12-31 | $28,988 |
| Employer contributions (assets) at beginning of year | 2013-12-31 | $30,254 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-12-31 | $3,060 |
| Contract administrator fees | 2013-12-31 | $102,572 |
| Did the plan have assets held for investment | 2013-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-12-31 | Unqualified |
| Accountancy firm name | 2013-12-31 | INEICH & COMPANY LLP |
| Accountancy firm EIN | 2013-12-31 | 562552172 |
| 2012 : ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN 2012 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2012-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $2,872 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $85,813 |
| Total income from all sources (including contributions) | 2012-12-31 | $1,149,069 |
| Total loss/gain on sale of assets | 2012-12-31 | $0 |
| Total of all expenses incurred | 2012-12-31 | $1,079,227 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-12-31 | $928,982 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-12-31 | $1,110,824 |
| Value of total assets at end of year | 2012-12-31 | $472,376 |
| Value of total assets at beginning of year | 2012-12-31 | $485,475 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-12-31 | $150,245 |
| Total interest from all sources | 2012-12-31 | $31 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-12-31 | $10,875 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2012-12-31 | $10,875 |
| Administrative expenses professional fees incurred | 2012-12-31 | $1,382 |
| Was this plan covered by a fidelity bond | 2012-12-31 | Yes |
| Value of fidelity bond cover | 2012-12-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2012-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-12-31 | $53,500 |
| Administrative expenses (other) incurred | 2012-12-31 | $22,888 |
| Liabilities. Value of operating payables at end of year | 2012-12-31 | $2,872 |
| Liabilities. Value of operating payables at beginning of year | 2012-12-31 | $20,813 |
| Total non interest bearing cash at end of year | 2012-12-31 | $83,230 |
| Total non interest bearing cash at beginning of year | 2012-12-31 | $27,288 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Value of net income/loss | 2012-12-31 | $69,842 |
| Value of net assets at end of year (total assets less liabilities) | 2012-12-31 | $469,504 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-12-31 | $399,662 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-12-31 | No |
| Investment advisory and management fees | 2012-12-31 | $3,748 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2012-12-31 | $353,756 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2012-12-31 | $386,005 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2012-12-31 | $5,136 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-12-31 | $6,779 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-12-31 | $6,779 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2012-12-31 | $31 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-12-31 | $925,487 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2012-12-31 | $27,339 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-12-31 | No |
| Contributions received in cash from employer | 2012-12-31 | $1,110,824 |
| Employer contributions (assets) at end of year | 2012-12-31 | $30,254 |
| Employer contributions (assets) at beginning of year | 2012-12-31 | $11,903 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-12-31 | $3,495 |
| Contract administrator fees | 2012-12-31 | $122,227 |
| Liabilities. Value of benefit claims payable at beginning of year | 2012-12-31 | $65,000 |
| Did the plan have assets held for investment | 2012-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-12-31 | Unqualified |
| Accountancy firm name | 2012-12-31 | INEICH & COMPANY, LLP |
| Accountancy firm EIN | 2012-12-31 | 562552172 |
| 2011 : ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN 2011 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2011-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $85,813 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $147,972 |
| Total income from all sources (including contributions) | 2011-12-31 | $1,021,281 |
| Total loss/gain on sale of assets | 2011-12-31 | $0 |
| Total of all expenses incurred | 2011-12-31 | $1,037,947 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-12-31 | $854,809 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-12-31 | $1,020,497 |
| Value of total assets at end of year | 2011-12-31 | $485,475 |
| Value of total assets at beginning of year | 2011-12-31 | $564,300 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-12-31 | $183,138 |
| Total interest from all sources | 2011-12-31 | $43 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-12-31 | No |
| Administrative expenses professional fees incurred | 2011-12-31 | $507 |
| Was this plan covered by a fidelity bond | 2011-12-31 | Yes |
| Value of fidelity bond cover | 2011-12-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2011-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Income. Received or receivable in cash from other sources (including rollovers) | 2011-12-31 | $9,224 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-12-31 | $53,500 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-12-31 | $915 |
| Administrative expenses (other) incurred | 2011-12-31 | $31,813 |
| Liabilities. Value of operating payables at end of year | 2011-12-31 | $20,813 |
| Liabilities. Value of operating payables at beginning of year | 2011-12-31 | $22,972 |
| Total non interest bearing cash at end of year | 2011-12-31 | $27,288 |
| Total non interest bearing cash at beginning of year | 2011-12-31 | $25,883 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Value of net income/loss | 2011-12-31 | $-16,666 |
| Value of net assets at end of year (total assets less liabilities) | 2011-12-31 | $399,662 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-12-31 | $416,328 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Investment advisory and management fees | 2011-12-31 | $4,547 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2011-12-31 | $386,005 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2011-12-31 | $513,688 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-12-31 | $6,779 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-12-31 | $13,941 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-12-31 | $13,941 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-12-31 | $43 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-12-31 | $249,710 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2011-12-31 | $741 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | No |
| Contributions received in cash from employer | 2011-12-31 | $1,011,273 |
| Employer contributions (assets) at end of year | 2011-12-31 | $11,903 |
| Employer contributions (assets) at beginning of year | 2011-12-31 | $9,873 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-12-31 | $605,099 |
| Contract administrator fees | 2011-12-31 | $146,271 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2011-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2011-12-31 | $65,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2011-12-31 | $125,000 |
| Did the plan have assets held for investment | 2011-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-12-31 | Unqualified |
| Accountancy firm name | 2011-12-31 | MOHLER, NIXON, & WILLIAMS |
| Accountancy firm EIN | 2011-12-31 | 770106234 |
| 2010 : ADA S. MCKINLEY COMMUNITY SERVICES, INC. H&W PLAN 2010 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2010-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $147,972 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $176,611 |
| Total income from all sources (including contributions) | 2010-12-31 | $977,030 |
| Total loss/gain on sale of assets | 2010-12-31 | $0 |
| Total of all expenses incurred | 2010-12-31 | $1,207,569 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2010-12-31 | $1,003,297 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2010-12-31 | $924,097 |
| Value of total assets at end of year | 2010-12-31 | $564,300 |
| Value of total assets at beginning of year | 2010-12-31 | $823,478 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2010-12-31 | $204,272 |
| Total interest from all sources | 2010-12-31 | $59 |
| Total dividends received (eg from common stock, registered investment company shares) | 2010-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2010-12-31 | No |
| Administrative expenses professional fees incurred | 2010-12-31 | $584 |
| Was this plan covered by a fidelity bond | 2010-12-31 | Yes |
| Value of fidelity bond cover | 2010-12-31 | $200,000 |
| If this is an individual account plan, was there a blackout period | 2010-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2010-12-31 | No |
| Income. Received or receivable in cash from other sources (including rollovers) | 2010-12-31 | $30,605 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2010-12-31 | $915 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2010-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2010-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2010-12-31 | $6,575 |
| Administrative expenses (other) incurred | 2010-12-31 | $53,055 |
| Liabilities. Value of operating payables at end of year | 2010-12-31 | $22,972 |
| Liabilities. Value of operating payables at beginning of year | 2010-12-31 | $25,036 |
| Total non interest bearing cash at end of year | 2010-12-31 | $25,883 |
| Total non interest bearing cash at beginning of year | 2010-12-31 | $3,173 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Value of net income/loss | 2010-12-31 | $-230,539 |
| Value of net assets at end of year (total assets less liabilities) | 2010-12-31 | $416,328 |
| Value of net assets at beginning of year (total assets less liabilities) | 2010-12-31 | $646,867 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2010-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2010-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2010-12-31 | No |
| Investment advisory and management fees | 2010-12-31 | $6,102 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2010-12-31 | $513,688 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2010-12-31 | $724,159 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2010-12-31 | $13,941 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2010-12-31 | $442 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2010-12-31 | $442 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2010-12-31 | $59 |
| Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year | 2010-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2010-12-31 | $215,093 |
| Net gain/loss from 103.12 investment entities | 2010-12-31 | $52,874 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2010-12-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2010-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2010-12-31 | No |
| Contributions received in cash from employer | 2010-12-31 | $893,492 |
| Employer contributions (assets) at end of year | 2010-12-31 | $9,873 |
| Employer contributions (assets) at beginning of year | 2010-12-31 | $95,704 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2010-12-31 | $788,204 |
| Contract administrator fees | 2010-12-31 | $144,531 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2010-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2010-12-31 | $125,000 |
| Liabilities. Value of benefit claims payable at beginning of year | 2010-12-31 | $145,000 |
| Did the plan have assets held for investment | 2010-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2010-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2010-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2010-12-31 | Unqualified |
| Accountancy firm name | 2010-12-31 | MOHLER, NIXON & WILLIAMS |
| Accountancy firm EIN | 2010-12-31 | 770106234 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0763594 |
| Policy instance | 4 |
| Insurance contract or identification number | 0763594 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $653,884 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 645742 |
| Policy instance | 3 |
| Insurance contract or identification number | VAR 645742 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $246 | | Total amount of fees paid to insurance company | USD $333 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,463 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $246 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 333 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645543 |
| Policy instance | 2 |
| Insurance contract or identification number | GL645543 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $182 | | Total amount of fees paid to insurance company | USD $307 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $182 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 307 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLLMBADA4 |
| Policy instance | 1 |
| Insurance contract or identification number | CLLMBADA4 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $86,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 210 |
| Policy instance | 1 |
| Insurance contract or identification number | 210 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,354 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | MNL-LMB-ADA1 |
| Policy instance | 2 |
| Insurance contract or identification number | MNL-LMB-ADA1 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,509 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $183,627 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,509 | | Insurance broker organization code? | 5 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS, INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645543 |
| Policy instance | 3 |
| Insurance contract or identification number | GL645543 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $398 | | Total amount of fees paid to insurance company | USD $437 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,977 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $398 | | Amount paid for insurance broker fees | 437 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645742 |
| Policy instance | 4 |
| Insurance contract or identification number | VAR645742 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $231 | | Total amount of fees paid to insurance company | USD $254 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $231 | | Amount paid for insurance broker fees | 254 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0743933 |
| Policy instance | 5 |
| Insurance contract or identification number | 0743933 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $567,473 | | 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 | PD-350 |
| Policy instance | 6 |
| Insurance contract or identification number | PD-350 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,751 | | 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 | PD-350 |
| Policy instance | 8 |
| Insurance contract or identification number | PD-350 | | Number of Individuals Covered | 84 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $45,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | MNL LMB ADA 4 |
| Policy instance | 7 |
| Insurance contract or identification number | MNL LMB ADA 4 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $407,964 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | MNL LMB ADA 3 |
| Policy instance | 6 |
| Insurance contract or identification number | MNL LMB ADA 3 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,525 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | MNL LMB ADA 2 |
| Policy instance | 5 |
| Insurance contract or identification number | MNL LMB ADA 2 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,441 | | 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 | 0743933 |
| Policy instance | 4 |
| Insurance contract or identification number | 0743933 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $516,804 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645742 |
| Policy instance | 3 |
| Insurance contract or identification number | VAR645742 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $168 | | Total amount of fees paid to insurance company | USD $605 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,307 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $168 | | Amount paid for insurance broker fees | 605 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645543 |
| Policy instance | 2 |
| Insurance contract or identification number | GL645543 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $281 | | Total amount of fees paid to insurance company | USD $1,002 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,494 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $281 | | Amount paid for insurance broker fees | 1002 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | MNL-LMB-ADA1 |
| Policy instance | 1 |
| Insurance contract or identification number | MNL-LMB-ADA1 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,097 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL-LMB-ADA1 |
| Policy instance | 1 |
| Insurance contract or identification number | SSL-LMB-ADA1 | | Number of Individuals Covered | 1 | | 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 $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645543 |
| Policy instance | 2 |
| Insurance contract or identification number | GL645543 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $130 | | Total amount of fees paid to insurance company | USD $1,249 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,810 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $130 | | Amount paid for insurance broker fees | 1249 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645742 |
| Policy instance | 3 |
| Insurance contract or identification number | VAR645742 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $75 | | Total amount of fees paid to insurance company | USD $753 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,503 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $75 | | Amount paid for insurance broker fees | 753 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL LMB ADA 2 |
| Policy instance | 5 |
| Insurance contract or identification number | SSL LMB ADA 2 | | Number of Individuals Covered | 13 | | 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 $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL LMB ADA 3 |
| Policy instance | 6 |
| Insurance contract or identification number | SSL LMB ADA 3 | | Number of Individuals Covered | 1081 | | 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 $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $286,020 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0743933 |
| Policy instance | 4 |
| Insurance contract or identification number | 0743933 | | Number of Individuals Covered | 77 | | 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 $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $519,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0743933 |
| Policy instance | 4 |
| Insurance contract or identification number | 0743933 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $655,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645742 |
| Policy instance | 3 |
| Insurance contract or identification number | VAR645742 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $108 | | Total amount of fees paid to insurance company | USD $811 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,773 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $108 | | Amount paid for insurance broker fees | 811 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645543 |
| Policy instance | 2 |
| Insurance contract or identification number | GL645543 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $176 | | Total amount of fees paid to insurance company | USD $1,394 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,481 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $176 | | Amount paid for insurance broker fees | 1394 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE & OTHER SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
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| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL-LMB-ADA1 |
| Policy instance | 1 |
| Insurance contract or identification number | SSL-LMB-ADA1 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $238,722 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL-P07-239R |
| Policy instance | 1 |
| Insurance contract or identification number | SSL-P07-239R | | Number of Individuals Covered | 186 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-09-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EXCESS LOSS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $194,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645543/VAR645 |
| Policy instance | 2 |
| Insurance contract or identification number | GL645543/VAR645 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $342 | | Total amount of fees paid to insurance company | USD $3,060 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,232 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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