401k Plan data: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN plan

FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 401k Plan overview

Plan Name	FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN
Plan identification number	502

FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN Benefits

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

401k Sponsoring company profile

FISHER PRINTING, INC. has sponsored the creation of one or more 401k plans.

Company Name: FISHER PRINTING, INC.

Employer identification number (EIN): 362443352

NAIC Classification: 323100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN

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

Plan Statistics for FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN

401k plan membership statisitcs for FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN

Measure Date Value
2022: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 144
Total of all active and inactive participants 2022-01-01 144
2021: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 117
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 269
Total of all active and inactive participants 2021-01-01 269
2020: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 117
Total of all active and inactive participants 2020-01-01 117
2019: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 132
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 119
Total of all active and inactive participants 2019-01-01 119
2018: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 132
Total of all active and inactive participants 2018-01-01 132
Total participants 2018-01-01 132
2017: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 125
Total of all active and inactive participants 2017-01-01 125
Total participants 2017-01-01 125
2016: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 116
Total of all active and inactive participants 2016-01-01 116
Total participants 2016-01-01 116
2015: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 111
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 112
Total of all active and inactive participants 2015-01-01 112
Total participants 2015-01-01 0
2014: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 111
Total of all active and inactive participants 2014-01-01 111
Total participants 2014-01-01 0
2013: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 108
Total of all active and inactive participants 2013-01-01 108
Total participants 2013-01-01 0
2012: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 110
Total of all active and inactive participants 2012-01-01 110
Total participants 2012-01-01 0
2011: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 104
Total of all active and inactive participants 2011-01-01 104
Total participants 2011-01-01 104
2009: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 105
Total of all active and inactive participants 2009-01-01 105
Total participants 2009-01-01 105

Measure	Date	Value
2022: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	144
Total of all active and inactive participants	2022-01-01	144
2021: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	117
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	269
Total of all active and inactive participants	2021-01-01	269
2020: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	117
Total of all active and inactive participants	2020-01-01	117
2019: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	132
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	119
Total of all active and inactive participants	2019-01-01	119
2018: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	132
Total of all active and inactive participants	2018-01-01	132
Total participants	2018-01-01	132
2017: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	125
Total of all active and inactive participants	2017-01-01	125
Total participants	2017-01-01	125
2016: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	116
Total of all active and inactive participants	2016-01-01	116
Total participants	2016-01-01	116
2015: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	111
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	112
Total of all active and inactive participants	2015-01-01	112
Total participants	2015-01-01	0
2014: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	111
Total of all active and inactive participants	2014-01-01	111
Total participants	2014-01-01	0
2013: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	108
Total of all active and inactive participants	2013-01-01	108
Total participants	2013-01-01	0
2012: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	110
Total of all active and inactive participants	2012-01-01	110
Total participants	2012-01-01	0
2011: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	104
Total of all active and inactive participants	2011-01-01	104
Total participants	2011-01-01	104
2009: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	105
Total of all active and inactive participants	2009-01-01	105
Total participants	2009-01-01	105

Form 5500 Responses for FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN

2022: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: FISHER PRINTING, INC MEDICAL, DENTAL, LIFE, AD&D INSURANCE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	54
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,810
Total amount of fees paid to insurance company	USD $1,390
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,810
Amount paid for insurance broker fees	1390
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	32
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,030
Total amount of fees paid to insurance company	USD $437
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,030
Amount paid for insurance broker fees	437
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	106
Insurance policy start date	2022-01-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $654
Total amount of fees paid to insurance company	USD $437
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $654
Amount paid for insurance broker fees	437
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	48
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,309
Total amount of fees paid to insurance company	USD $554
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,309
Amount paid for insurance broker fees	554
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	144
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,234
Total amount of fees paid to insurance company	USD $164
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $8,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,234
Amount paid for insurance broker fees	164
Insurance broker organization code?	3

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )

Policy contract number

EMCL21100441005

Policy instance

Insurance contract or identification number	EMCL21100441005
Number of Individuals Covered	98
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $265,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	20
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $988
Total amount of fees paid to insurance company	USD $262
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $988
Amount paid for insurance broker fees	262
Insurance broker organization code?	3

CURALINC HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

02045

Policy instance

Insurance contract or identification number	02045
Number of Individuals Covered	144
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE/COUNSELING
Welfare Benefit Premiums Paid to Carrier	USD $4,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	36
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,822
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,822
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	100
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,211
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,211
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	269
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $684
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $4,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $684
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	51
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,256
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,256
Insurance broker organization code?	3

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )

Policy contract number

EMCL19100441005

Policy instance

Insurance contract or identification number	EMCL19100441005
Number of Individuals Covered	105
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $315,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	25
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,028
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,028
Insurance broker organization code?	3

CURALINC HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

02045

Policy instance

Insurance contract or identification number	02045
Number of Individuals Covered	225
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE/COUNSELING
Welfare Benefit Premiums Paid to Carrier	USD $4,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BV9X

Policy instance

Insurance contract or identification number	G000BV9X
Number of Individuals Covered	56
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,106
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,106
Insurance broker organization code?	3

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

Policy contract number

02459

Policy instance

Insurance contract or identification number	02459
Number of Individuals Covered	19
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $931
Total amount of fees paid to insurance company	USD $788
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $931
Amount paid for insurance broker fees	42
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

10153116

Policy instance

Insurance contract or identification number	10153116
Number of Individuals Covered	117
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,138
Total amount of fees paid to insurance company	USD $426
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $5,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,138
Amount paid for insurance broker fees	40
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

00659

Policy instance

Insurance contract or identification number	00659
Number of Individuals Covered	19
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,243
Total amount of fees paid to insurance company	USD $1,024
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,243
Amount paid for insurance broker fees	47
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

UNITED HEALTHCARE OF THE RIVER VALLEY (National Association of Insurance Commissioners NAIC id number: 70254 )

Policy contract number

U801050

Policy instance

Insurance contract or identification number	U801050
Number of Individuals Covered	68
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,007
Total amount of fees paid to insurance company	USD $364
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $913
Insurance broker organization code?	3
Amount paid for insurance broker fees	364
Additional information about fees paid to insurance broker	ADMIN

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

Policy contract number

10226

Policy instance

Insurance contract or identification number	10226
Number of Individuals Covered	22
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,927
Total amount of fees paid to insurance company	USD $1,585
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,927
Amount paid for insurance broker fees	66
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )

Policy contract number

EMCL18100441

Policy instance

Insurance contract or identification number	EMCL18100441
Number of Individuals Covered	79
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $34,794
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $231,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,794
Insurance broker organization code?	3

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

Policy contract number

00508650

Policy instance

Insurance contract or identification number	00508650
Number of Individuals Covered	36
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,017
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,997
Insurance broker organization code?	3

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

Policy contract number

00508650

Policy instance

Insurance contract or identification number	00508650
Number of Individuals Covered	37
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,368
Total amount of fees paid to insurance company	USD $793
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,345
Amount paid for insurance broker fees	793
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

10226

Policy instance

Insurance contract or identification number	10226
Number of Individuals Covered	22
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,599
Total amount of fees paid to insurance company	USD $1,357
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,599
Amount paid for insurance broker fees	57
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

UNITED HEALTHCARE OF THE RIVER VALLEY (National Association of Insurance Commissioners NAIC id number: 70254 )

Policy contract number

U801050

Policy instance

Insurance contract or identification number	U801050
Number of Individuals Covered	65
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,947
Total amount of fees paid to insurance company	USD $353
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $885
Insurance broker organization code?	3
Amount paid for insurance broker fees	353
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

00659

Policy instance

Insurance contract or identification number	00659
Number of Individuals Covered	20
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,025
Total amount of fees paid to insurance company	USD $877
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,025
Amount paid for insurance broker fees	38
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

10153116

Policy instance

Insurance contract or identification number	10153116
Number of Individuals Covered	119
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,087
Total amount of fees paid to insurance company	USD $426
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $5,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,087
Amount paid for insurance broker fees	31
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )

Policy contract number

EMC L18100441

Policy instance

Insurance contract or identification number	EMC L18100441
Number of Individuals Covered	119
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $47,629
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $317,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,629
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

02459

Policy instance

Insurance contract or identification number	02459
Number of Individuals Covered	20
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $868
Total amount of fees paid to insurance company	USD $758
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $868
Amount paid for insurance broker fees	37
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )

Policy contract number

01-0153116

Policy instance

Insurance contract or identification number	01-0153116
Number of Individuals Covered	132
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,755
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,755
Insurance broker organization code?	3

UNITEDHEALTH GROUP (OPTUM) (National Association of Insurance Commissioners NAIC id number: 2759 )

Policy contract number

U801050

Policy instance

Insurance contract or identification number	U801050
Number of Individuals Covered	70
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,861
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $931
Insurance broker organization code?	3

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

Policy contract number

00659

Policy instance

Insurance contract or identification number	00659
Number of Individuals Covered	21
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,161
Total amount of fees paid to insurance company	USD $1,097
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,161
Amount paid for insurance broker fees	168
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

02459

Policy instance

Insurance contract or identification number	02459
Number of Individuals Covered	24
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,097
Total amount of fees paid to insurance company	USD $986
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,097
Amount paid for insurance broker fees	130
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )

Policy contract number

EMC L18100441

Policy instance

Insurance contract or identification number	EMC L18100441
Number of Individuals Covered	132
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $44,231
Welfare Benefit Premiums Paid to Carrier	USD $294,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,231
Insurance broker organization code?	3

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

Policy contract number

00508650

Policy instance

Insurance contract or identification number	00508650
Number of Individuals Covered	37
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,001
Total amount of fees paid to insurance company	USD $844
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,981
Amount paid for insurance broker fees	844
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

10226

Policy instance

Insurance contract or identification number	10226
Number of Individuals Covered	23
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,682
Total amount of fees paid to insurance company	USD $1,572
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,682
Amount paid for insurance broker fees	223
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

10153116

Policy instance

Insurance contract or identification number	10153116
Number of Individuals Covered	128
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,236
Total amount of fees paid to insurance company	USD $542
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $6,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,236
Amount paid for insurance broker fees	116
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

10226

Policy instance

Insurance contract or identification number	10226
Number of Individuals Covered	43
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,646
Total amount of fees paid to insurance company	USD $1,475
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,646
Amount paid for insurance broker fees	199
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARK S. METTILLE

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

Policy contract number

02459

Policy instance

Insurance contract or identification number	02459
Number of Individuals Covered	22
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $986
Total amount of fees paid to insurance company	USD $896
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $986
Amount paid for insurance broker fees	126
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARK S METTILLE

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

Policy contract number

E7116346

Policy instance

Insurance contract or identification number	E7116346
Number of Individuals Covered	1
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12
Insurance broker organization code?	3
Insurance broker name	SHERI B. MELLIN

JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )

Policy contract number

01-0153116

Policy instance

Insurance contract or identification number	01-0153116
Number of Individuals Covered	124
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,449
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,449
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP INC.

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

Policy contract number

00659

Policy instance

Insurance contract or identification number	00659
Number of Individuals Covered	25
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,270
Total amount of fees paid to insurance company	USD $1,172
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	423
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $1,270
Insurance broker name	MARK S METTILLE

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

Policy contract number

HCL31599

Policy instance

Insurance contract or identification number	HCL31599
Number of Individuals Covered	124
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $40,675
Welfare Benefit Premiums Paid to Carrier	USD $271,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,675
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP INC.

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	84
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,810
Total amount of fees paid to insurance company	USD $328
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $823
Insurance broker organization code?	3
Amount paid for insurance broker fees	328
Additional information about fees paid to insurance broker	FEES
Insurance broker name	BOON CHAPMAN BNFT ADMNSTRS INC.

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

Policy contract number

00508650

Policy instance

Insurance contract or identification number	00508650
Number of Individuals Covered	37
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,131
Total amount of fees paid to insurance company	USD $915
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,110
Amount paid for insurance broker fees	915
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	THE HUNKEN AGENCY, INC.

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

Policy contract number

10153116

Policy instance

Insurance contract or identification number	10153116
Number of Individuals Covered	125
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,159
Total amount of fees paid to insurance company	USD $488
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $5,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,159
Amount paid for insurance broker fees	98
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARK S METTILLE

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

Policy contract number

10226

Policy instance

Insurance contract or identification number	10226
Number of Individuals Covered	37
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,261
Total amount of fees paid to insurance company	USD $127
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,261
Insurance broker organization code?	3
Amount paid for insurance broker fees	127
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	THE HORTON GROUP

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

Policy contract number

02459

Policy instance

Insurance contract or identification number	02459
Number of Individuals Covered	16
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $724
Total amount of fees paid to insurance company	USD $77
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $724
Insurance broker organization code?	3
Amount paid for insurance broker fees	77
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	THE HORTON GROUP

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

Policy contract number

E7116346

Policy instance

Insurance contract or identification number	E7116346
Number of Individuals Covered	2
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $23
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23
Insurance broker organization code?	3
Insurance broker name	SHERI B. MELLIN

JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )

Policy contract number

01-0153116

Policy instance

Insurance contract or identification number	01-0153116
Number of Individuals Covered	112
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $990
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $990
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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

Policy contract number

10153116

Policy instance

Insurance contract or identification number	10153116
Number of Individuals Covered	106
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $792
Total amount of fees paid to insurance company	USD $280
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $3,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $792
Amount paid for insurance broker fees	82
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARK S. METTILLE

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

Policy contract number

HCL31599

Policy instance

Insurance contract or identification number	HCL31599
Number of Individuals Covered	112
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $42,375
Welfare Benefit Premiums Paid to Carrier	USD $282,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,375
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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

Policy contract number

00508650

Policy instance

Insurance contract or identification number	00508650
Number of Individuals Covered	40
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,945
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,810
Insurance broker organization code?	3
Insurance broker name	THE HUNKEN AGENCY INC

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	51
Insurance policy start date	2015-01-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $888
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $507
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

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

Policy contract number

00659

Policy instance

Insurance contract or identification number	00659
Number of Individuals Covered	21
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $933
Total amount of fees paid to insurance company	USD $106
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $933
Insurance broker organization code?	3
Amount paid for insurance broker fees	106
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	THE HORTON GROUP

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

Policy contract number

10226

Policy instance

Insurance contract or identification number	10226
Number of Individuals Covered	34
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,651
Total amount of fees paid to insurance company	USD $170
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,651
Insurance broker organization code?	3
Amount paid for insurance broker fees	170
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	THE HORTON GROUP

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	33
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,045
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $597
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 )

Policy contract number

01-0153116

Policy instance

Insurance contract or identification number	01-0153116
Number of Individuals Covered	111
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,063
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,063
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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

Policy contract number

02459

Policy instance

Insurance contract or identification number	02459
Number of Individuals Covered	13
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,001
Total amount of fees paid to insurance company	USD $99
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,001
Insurance broker organization code?	3
Amount paid for insurance broker fees	99
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	THE HORTON GROUP

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

Policy contract number

10153116

Policy instance

Insurance contract or identification number	10153116
Number of Individuals Covered	105
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $850
Total amount of fees paid to insurance company	USD $325
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $4,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $850
Amount paid for insurance broker fees	112
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARK S. METTILLE

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

Policy contract number

00659

Policy instance

Insurance contract or identification number	00659
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 $1,377
Total amount of fees paid to insurance company	USD $133
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,377
Insurance broker organization code?	3
Amount paid for insurance broker fees	133
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	GROUP INSURANCE SERVICES, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

118432

Policy instance

Insurance contract or identification number	118432
Number of Individuals Covered	33
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,178
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,633
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

404459-A

Policy instance

Insurance contract or identification number	404459-A
Number of Individuals Covered	111
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $45,360
Welfare Benefit Premiums Paid to Carrier	USD $302,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,360
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

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

Policy contract number

E7116346

Policy instance

Insurance contract or identification number	E7116346
Number of Individuals Covered	2
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $23
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23
Insurance broker organization code?	3
Insurance broker name	SHERI B. MELLIN

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

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	19
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $939
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $704
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

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

Policy contract number

10153116

Policy instance

Insurance contract or identification number	10153116
Number of Individuals Covered	108
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $642
Total amount of fees paid to insurance company	USD $311
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $3,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $642
Amount paid for insurance broker fees	151
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARK S. METTILLE

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

Policy contract number

E7116346

Policy instance

Insurance contract or identification number	E7116346
Number of Individuals Covered	2
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $23
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23
Insurance broker organization code?	3
Insurance broker name	SHERI B. MELLIN

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

404459-A

Policy instance

Insurance contract or identification number	404459-A
Number of Individuals Covered	110
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $37,586
Welfare Benefit Premiums Paid to Carrier	USD $250,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,586
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	33
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,783
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,087
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

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

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	11
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $293
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $220
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

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

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	8
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $36
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

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

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
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 $667
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $500
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	40
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $955
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $546
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

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

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	20
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $836
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $627
Insurance broker organization code?	3
Insurance broker name	GROUP INSURANCE SERVICES, INC.

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

Policy contract number

40000200002459

Policy instance

Insurance contract or identification number	40000200002459
Number of Individuals Covered	15
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $873
Total amount of fees paid to insurance company	USD $119
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $3,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	119
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $356
Insurance broker name	EMPLOYER PLAN SERVICES INC.

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

Policy contract number

40000100010226

Policy instance

Insurance contract or identification number	40000100010226
Number of Individuals Covered	22
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,701
Total amount of fees paid to insurance company	USD $260
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	260
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $792
Insurance broker name	EMPLOYER PLAN SERVICES INC.

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

Policy contract number

40000300100659

Policy instance

Insurance contract or identification number	40000300100659
Number of Individuals Covered	20
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,706
Total amount of fees paid to insurance company	USD $157
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	157
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $669
Insurance broker name	EMPLOYER PLAN SERVICES INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 118432

Policy instance

Insurance contract or identification number	LTD 118432
Number of Individuals Covered	32
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,228
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $557
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP INC.

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	43
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,172
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $502
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP INC.

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

Policy contract number

E7116346

Policy instance

Insurance contract or identification number	E7116346
Number of Individuals Covered	2
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $21
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21
Insurance broker organization code?	3
Insurance broker name	SHERI B. MELLIN

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

IHCRS-00005-12

Policy instance

Insurance contract or identification number	IHCRS-00005-12
Number of Individuals Covered	103
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $30,872
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $203,567
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,872
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP INC.

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

Policy contract number

1015311600000

Policy instance

Insurance contract or identification number	1015311600000
Number of Individuals Covered	110
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $619
Total amount of fees paid to insurance company	USD $155
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $3,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	155
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $280
Insurance broker name	EDWARD C. YOUNG

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

Policy contract number

40000200002459

Policy instance

Insurance contract or identification number	40000200002459
Number of Individuals Covered	14
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $797
Total amount of fees paid to insurance company	USD $36
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $3,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

403286-A

Policy instance

Insurance contract or identification number	403286-A
Number of Individuals Covered	104
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $33,577
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $223,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

40000100010226

Policy instance

Insurance contract or identification number	40000100010226
Number of Individuals Covered	23
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,738
Total amount of fees paid to insurance company	USD $78
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

40000300100659

Policy instance

Insurance contract or identification number	40000300100659
Number of Individuals Covered	16
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,046
Total amount of fees paid to insurance company	USD $47
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,184
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

LTD 118432

Policy instance

Insurance contract or identification number	LTD 118432
Number of Individuals Covered	33
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,575
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,863
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

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	32
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $875
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7116346

Policy instance

Insurance contract or identification number	E7116346
Number of Individuals Covered	2
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $22
Welfare Benefit Premiums Paid to Carrier	USD $1,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

40000200002459

Policy instance

Insurance contract or identification number	40000200002459
Number of Individuals Covered	15
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $805
Total amount of fees paid to insurance company	USD $23
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $3,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	23
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $805
Insurance broker name	EPSI BENEFITS, INC

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

UP650F

Policy instance

Insurance contract or identification number	UP650F
Number of Individuals Covered	110
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $30,868
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $205,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,868
Insurance broker organization code?	3
Insurance broker name	THE HORTON GROUP INC

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

Policy contract number

40000100010226

Policy instance

Insurance contract or identification number	40000100010226
Number of Individuals Covered	24
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,739
Total amount of fees paid to insurance company	USD $47
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	47
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $1,739
Insurance broker name	EPSI BENEFITS, INC

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

Policy contract number

40000300100659

Policy instance

Insurance contract or identification number	40000300100659
Number of Individuals Covered	16
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,049
Total amount of fees paid to insurance company	USD $29
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	29
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $1,049
Insurance broker name	EPSI BENEFITS, INC.

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	32
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,869
Total amount of fees paid to insurance company	USD $467
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	467
Additional information about fees paid to insurance broker	ADMINISTRATION FEES
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $467
Insurance broker name	THE HORTON GROUP INC

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

M001072

Policy instance

Insurance contract or identification number	M001072
Number of Individuals Covered	34
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $962
Total amount of fees paid to insurance company	USD $275
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	275
Additional information about fees paid to insurance broker	ADMINISTRATION FEES
Commission paid to Insurance Broker	USD $412
Insurance broker organization code?	3
Insurance broker name	THE HOURTON GROUP INC

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Company Name:	FISHER PRINTING, INC.
Employer identification number (EIN):	362443352
NAIC Classification:	323100