401k Plan data: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN plan

VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 401k Plan overview

Plan Name	VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN
Plan identification number	501

VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN Benefits

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

401k Sponsoring company profile

VICTORY ENERGY OPERATIONS, L.L.C. has sponsored the creation of one or more 401k plans.

Company Name: VICTORY ENERGY OPERATIONS, L.L.C.

Employer identification number (EIN): 364286198

NAIC Classification: 332400

Form 5500 Filing Information

Submission information for form 5500 for 401k plan VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 JOHN C. VISKUP, JR. 2023-10-10
501 2021-01-01 JOHN C. VISKUP, JR. 2022-09-27
501 2020-01-01 JOHN C. VISKUP, JR. 2021-09-30
501 2019-01-01 JOHN C. VISKUP, JR. 2020-10-05
501 2018-01-01 JOHN C. VISKUP, JR. 2019-10-08
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 JOHN C. VISKUP JR.
501 2009-10-01 JOHN VISKUP
501 2008-10-01 JOHN VISKUP

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	JOHN C. VISKUP, JR.	2023-10-10
501	2021-01-01	JOHN C. VISKUP, JR.	2022-09-27
501	2020-01-01	JOHN C. VISKUP, JR.	2021-09-30
501	2019-01-01	JOHN C. VISKUP, JR.	2020-10-05
501	2018-01-01	JOHN C. VISKUP, JR.	2019-10-08
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	JOHN C. VISKUP JR.
501	2009-10-01	JOHN VISKUP
501	2008-10-01	JOHN VISKUP

Plan Statistics for VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN

401k plan membership statisitcs for VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN

Measure Date Value
2022: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 220
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 201
Number of retired or separated participants receiving benefits 2022-01-01 2
Number of other retired or separated participants entitled to future benefits 2022-01-01 36
Total of all active and inactive participants 2022-01-01 239
2021: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 223
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 182
Number of retired or separated participants receiving benefits 2021-01-01 2
Number of other retired or separated participants entitled to future benefits 2021-01-01 35
Total of all active and inactive participants 2021-01-01 219
2020: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 181
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 186
Number of retired or separated participants receiving benefits 2020-01-01 1
Number of other retired or separated participants entitled to future benefits 2020-01-01 36
Total of all active and inactive participants 2020-01-01 223
2019: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 173
Number of retired or separated participants receiving benefits 2019-01-01 1
Number of other retired or separated participants entitled to future benefits 2019-01-01 7
Total of all active and inactive participants 2019-01-01 181
2018: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 177
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 153
Number of retired or separated participants receiving benefits 2018-01-01 1
Total of all active and inactive participants 2018-01-01 154
2017: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 176
Number of retired or separated participants receiving benefits 2017-01-01 1
Total of all active and inactive participants 2017-01-01 177
2016: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 212
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 229
Number of retired or separated participants receiving benefits 2016-01-01 1
Total of all active and inactive participants 2016-01-01 230
2015: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 208
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 212
Total of all active and inactive participants 2015-01-01 212
2014: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 170
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 207
Number of other retired or separated participants entitled to future benefits 2014-01-01 1
Total of all active and inactive participants 2014-01-01 208
2013: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 170
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 169
Number of other retired or separated participants entitled to future benefits 2013-01-01 1
Total of all active and inactive participants 2013-01-01 170
2012: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 143
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 173
Total of all active and inactive participants 2012-01-01 173
2009: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-10-01 150
Total number of active participants reported on line 7a of the Form 5500 2009-10-01 108
Number of retired or separated participants receiving benefits 2009-10-01 12
Total of all active and inactive participants 2009-10-01 120
2008: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year 2008-10-01 170
Total number of active participants reported on line 7a of the Form 5500 2008-10-01 136
Number of retired or separated participants receiving benefits 2008-10-01 14
Total of all active and inactive participants 2008-10-01 150

Measure	Date	Value
2022: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	220
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	201
Number of retired or separated participants receiving benefits	2022-01-01	2
Number of other retired or separated participants entitled to future benefits	2022-01-01	36
Total of all active and inactive participants	2022-01-01	239
2021: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	223
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	182
Number of retired or separated participants receiving benefits	2021-01-01	2
Number of other retired or separated participants entitled to future benefits	2021-01-01	35
Total of all active and inactive participants	2021-01-01	219
2020: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	181
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	186
Number of retired or separated participants receiving benefits	2020-01-01	1
Number of other retired or separated participants entitled to future benefits	2020-01-01	36
Total of all active and inactive participants	2020-01-01	223
2019: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	173
Number of retired or separated participants receiving benefits	2019-01-01	1
Number of other retired or separated participants entitled to future benefits	2019-01-01	7
Total of all active and inactive participants	2019-01-01	181
2018: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	177
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	153
Number of retired or separated participants receiving benefits	2018-01-01	1
Total of all active and inactive participants	2018-01-01	154
2017: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	176
Number of retired or separated participants receiving benefits	2017-01-01	1
Total of all active and inactive participants	2017-01-01	177
2016: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	212
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	229
Number of retired or separated participants receiving benefits	2016-01-01	1
Total of all active and inactive participants	2016-01-01	230
2015: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	208
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	212
Total of all active and inactive participants	2015-01-01	212
2014: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	207
Number of other retired or separated participants entitled to future benefits	2014-01-01	1
Total of all active and inactive participants	2014-01-01	208
2013: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	169
Number of other retired or separated participants entitled to future benefits	2013-01-01	1
Total of all active and inactive participants	2013-01-01	170
2012: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	143
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	173
Total of all active and inactive participants	2012-01-01	173
2009: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-10-01	150
Total number of active participants reported on line 7a of the Form 5500	2009-10-01	108
Number of retired or separated participants receiving benefits	2009-10-01	12
Total of all active and inactive participants	2009-10-01	120
2008: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year	2008-10-01	170
Total number of active participants reported on line 7a of the Form 5500	2008-10-01	136
Number of retired or separated participants receiving benefits	2008-10-01	14
Total of all active and inactive participants	2008-10-01	150

Form 5500 Responses for VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN

2022: VICTORY ENERGY OPERATIONS, LLC BENEFIT 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 benefit arrangement – Insurance	Yes
2021: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2009: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2009 form 5500 responses
2009-10-01	Type of plan entity	Single employer plan
2009-10-01	This submission is the final filing	No
2009-10-01	Plan funding arrangement – Insurance	Yes
2009-10-01	Plan benefit arrangement – Insurance	Yes
2008: VICTORY ENERGY OPERATIONS, LLC BENEFIT PLAN 2008 form 5500 responses
2008-10-01	Type of plan entity	Single employer plan
2008-10-01	First time form 5500 has been submitted	Yes
2008-10-01	Plan funding arrangement – Insurance	Yes
2008-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

HCL32763

Policy instance

Insurance contract or identification number	HCL32763
Number of Individuals Covered	153
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $472,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	157
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $10,664
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,664
Insurance broker organization code?	3

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

Policy contract number

30000990

Policy instance

Insurance contract or identification number	30000990
Number of Individuals Covered	140
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,297
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,297
Insurance broker organization code?	3

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

Policy contract number

GUPR0B9PH

Policy instance

Insurance contract or identification number	GUPR0B9PH
Number of Individuals Covered	124
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,483
Total amount of fees paid to insurance company	USD $2,218
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,483
Amount paid for insurance broker fees	2218
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUG 0B9PH

Policy instance

Insurance contract or identification number	GUG 0B9PH
Number of Individuals Covered	200
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,716
Total amount of fees paid to insurance company	USD $3,915
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,716
Amount paid for insurance broker fees	3915
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0B9PH

Policy instance

Insurance contract or identification number	GVTL0B9PH
Number of Individuals Covered	96
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,906
Total amount of fees paid to insurance company	USD $1,912
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $39,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,906
Amount paid for insurance broker fees	1912
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0B9PH

Policy instance

Insurance contract or identification number	GLUG0B9PH
Number of Individuals Covered	200
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,545
Total amount of fees paid to insurance company	USD $1,564
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,545
Amount paid for insurance broker fees	1564
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	149
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,278
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,278
Insurance broker organization code?	3

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

Policy contract number

30000990

Policy instance

Insurance contract or identification number	30000990
Number of Individuals Covered	120
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,216
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,216
Insurance broker organization code?	3

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

Policy contract number

GUPR0B9PH

Policy instance

Insurance contract or identification number	GUPR0B9PH
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 $3,168
Total amount of fees paid to insurance company	USD $1,887
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,168
Amount paid for insurance broker fees	1887
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUG 0B9PH

Policy instance

Insurance contract or identification number	GUG 0B9PH
Number of Individuals Covered	183
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,593
Total amount of fees paid to insurance company	USD $3,076
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,593
Amount paid for insurance broker fees	3076
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0B9PH

Policy instance

Insurance contract or identification number	GVTL0B9PH
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 $2,732
Total amount of fees paid to insurance company	USD $1,639
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,732
Amount paid for insurance broker fees	1639
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0B9PH

Policy instance

Insurance contract or identification number	GLUG0B9PH
Number of Individuals Covered	184
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,234
Total amount of fees paid to insurance company	USD $1,213
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,234
Amount paid for insurance broker fees	1213
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

HCL32763

Policy instance

Insurance contract or identification number	HCL32763
Number of Individuals Covered	128
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $461,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	140
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,052
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,052
Insurance broker organization code?	3

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

Policy contract number

30000990

Policy instance

Insurance contract or identification number	30000990
Number of Individuals Covered	118
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,235
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,235
Insurance broker organization code?	3

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

Policy contract number

GUPR0B9PH

Policy instance

Insurance contract or identification number	GUPR0B9PH
Number of Individuals Covered	102
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,426
Total amount of fees paid to insurance company	USD $2,354
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,426
Amount paid for insurance broker fees	2354
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUG 0B9PH

Policy instance

Insurance contract or identification number	GUG 0B9PH
Number of Individuals Covered	186
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,571
Total amount of fees paid to insurance company	USD $3,414
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,571
Amount paid for insurance broker fees	3414
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0B9PH

Policy instance

Insurance contract or identification number	GVTL0B9PH
Number of Individuals Covered	53
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,952
Total amount of fees paid to insurance company	USD $1,666
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $29,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,952
Amount paid for insurance broker fees	1666
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0B9PH

Policy instance

Insurance contract or identification number	GLUG0B9PH
Number of Individuals Covered	186
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,194
Total amount of fees paid to insurance company	USD $1,350
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,194
Amount paid for insurance broker fees	1350
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

HCL32763

Policy instance

Insurance contract or identification number	HCL32763
Number of Individuals Covered	143
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $459,552
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

GLUG0B9PH

Policy instance

Insurance contract or identification number	GLUG0B9PH
Number of Individuals Covered	177
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,833
Total amount of fees paid to insurance company	USD $1,457
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $18,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,833
Amount paid for insurance broker fees	1457
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0B9PH

Policy instance

Insurance contract or identification number	GVTL0B9PH
Number of Individuals Covered	55
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,286
Total amount of fees paid to insurance company	USD $2,602
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,286
Amount paid for insurance broker fees	2602
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUG 0B9PH

Policy instance

Insurance contract or identification number	GUG 0B9PH
Number of Individuals Covered	177
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,627
Total amount of fees paid to insurance company	USD $3,770
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,627
Amount paid for insurance broker fees	3770
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUPR0B9PH

Policy instance

Insurance contract or identification number	GUPR0B9PH
Number of Individuals Covered	102
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,225
Total amount of fees paid to insurance company	USD $2,747
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,225
Amount paid for insurance broker fees	2747
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

30000990

Policy instance

Insurance contract or identification number	30000990
Number of Individuals Covered	118
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,155
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,155
Insurance broker organization code?	3

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	134
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $8,096
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,096
Insurance broker organization code?	3

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

Policy contract number

HCL32763

Policy instance

Insurance contract or identification number	HCL32763
Number of Individuals Covered	132
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,412
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $341,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,412
Insurance broker organization code?	3

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	126
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,671
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,671
Insurance broker organization code?	3

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

Policy contract number

HCL32763

Policy instance

Insurance contract or identification number	HCL32763
Number of Individuals Covered	134
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,057
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $308,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,057
Insurance broker organization code?	3

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

Policy contract number

GLUG0B9PH

Policy instance

Insurance contract or identification number	GLUG0B9PH
Number of Individuals Covered	154
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,742
Total amount of fees paid to insurance company	USD $833
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,742
Amount paid for insurance broker fees	833
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0B9PH

Policy instance

Insurance contract or identification number	GVTL0B9PH
Number of Individuals Covered	55
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,735
Total amount of fees paid to insurance company	USD $1,487
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,735
Insurance broker organization code?	3
Amount paid for insurance broker fees	1487
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

GUG 0B9PH

Policy instance

Insurance contract or identification number	GUG 0B9PH
Number of Individuals Covered	154
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,538
Total amount of fees paid to insurance company	USD $2,154
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,538
Insurance broker organization code?	3
Amount paid for insurance broker fees	2154
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

GUPR0B9PH

Policy instance

Insurance contract or identification number	GUPR0B9PH
Number of Individuals Covered	95
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,266
Total amount of fees paid to insurance company	USD $1,570
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,266
Amount paid for insurance broker fees	1570
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

30000990

Policy instance

Insurance contract or identification number	30000990
Number of Individuals Covered	105
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,134
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,134
Insurance broker organization code?	3

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

Policy contract number

HCL32763

Policy instance

Insurance contract or identification number	HCL32763
Number of Individuals Covered	143
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,298
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $314,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,298
Insurance broker organization code?	3
Insurance broker name	RISK & INSURANCE CONSULTING SERVICE

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	247
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	247
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	252
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $21,963
Total amount of fees paid to insurance company	USD $73
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,245
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION
Insurance broker organization code?	3
Amount paid for insurance broker fees	73
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	177
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

30000990

Policy instance

Insurance contract or identification number	30000990
Number of Individuals Covered	126
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,298
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,298
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LIMITED

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	147
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,908
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,908
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL CFR

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	212
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	213
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	147
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,122
Total amount of fees paid to insurance company	USD $74
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,069
Insurance broker organization code?	3
Amount paid for insurance broker fees	74
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISTANCE, USA

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

Policy contract number

HCL30936

Policy instance

Insurance contract or identification number	HCL30936
Number of Individuals Covered	161
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,498
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $274,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,498
Insurance broker organization code?	3
Insurance broker name	RISK & INSURANCE CONSULTING SERVICE

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

30000990

Policy instance

Insurance contract or identification number	30000990
Number of Individuals Covered	141
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,274
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $781
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION, INC

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	168
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,717
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,440
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION INC

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	212
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
Other welfare benefits provided	AD&D
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

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	209
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	209
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $8,271
Total amount of fees paid to insurance company	USD $72
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,271
Insurance broker organization code?	3
Amount paid for insurance broker fees	72
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISSTANCE, USA

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	147
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

Policy instance

Number of Individuals Covered	141
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,174
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $208,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,174
Insurance broker organization code?	3
Insurance broker name	RISK & INSURANCE CONSULTING SERVICE

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

300000990

Policy instance

Insurance contract or identification number	300000990
Number of Individuals Covered	119
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,119
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,119
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	150
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,108
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,108
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	207
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	207
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

854540G

Policy instance

Insurance contract or identification number	854540G
Number of Individuals Covered	167
Insurance policy start date	2012-10-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $3,001
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,001
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	133
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,187
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,187
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

300000990

Policy instance

Insurance contract or identification number	300000990
Number of Individuals Covered	107
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,076
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,076
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION

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

Policy contract number

Policy instance

Number of Individuals Covered	124
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OPTUMHEALTH, A DIVISION OF UNITED HEALTHCARE SERVICES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

Policy instance

Number of Individuals Covered	124
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	124
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,033
Total amount of fees paid to insurance company	USD $54
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,033
Insurance broker organization code?	3
Amount paid for insurance broker fees	54
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION FEES
Insurance broker name	AXA ASSISSTANCE, USA

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	169
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	169
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	169
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

22428

Policy instance

Insurance contract or identification number	22428
Number of Individuals Covered	169
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,530
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

0715174

Policy instance

Insurance contract or identification number	0715174
Number of Individuals Covered	254
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $20,071
Total amount of fees paid to insurance company	USD $1,400
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $803,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,071
Amount paid for insurance broker fees	1400
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	132
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,909
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,909
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

300000990

Policy instance

Insurance contract or identification number	300000990
Number of Individuals Covered	107
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,100
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,100
Insurance broker organization code?	3
Insurance broker name	THE HOLMES ORGANISATION

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

Policy contract number

854540G

Policy instance

Insurance contract or identification number	854540G
Number of Individuals Covered	155
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $10,494
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $69,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,536
Insurance broker organization code?	3
Insurance broker name	SUMMIT FINANCIAL GROUP

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	94
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $4,383
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

854540G

Policy instance

Insurance contract or identification number	854540G
Number of Individuals Covered	119
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $7,209
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $48,065
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

0715174

Policy instance

Insurance contract or identification number	0715174
Number of Individuals Covered	293
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $37,642
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $752,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

854540G

Policy instance

Insurance contract or identification number	854540G
Number of Individuals Covered	178
Insurance policy start date	2008-10-01
Insurance policy end date	2009-09-30
Total amount of commissions paid to insurance broker	USD $7,745
Total amount of fees paid to insurance company	USD $1,051
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $51,634
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

0715174

Policy instance

Insurance contract or identification number	0715174
Number of Individuals Covered	381
Insurance policy start date	2008-10-01
Insurance policy end date	2009-09-30
Total amount of commissions paid to insurance broker	USD $57,495
Total amount of fees paid to insurance company	USD $2,500
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,149,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

3046

Policy instance

Insurance contract or identification number	3046
Number of Individuals Covered	156
Insurance policy start date	2008-10-01
Insurance policy end date	2009-09-30
Total amount of commissions paid to insurance broker	USD $7,698
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

VICTORY ENERGY CORPORATION RETIREMENT SAVINGS PLAN [EIN = 251645485]

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Company Name:	VICTORY ENERGY OPERATIONS, L.L.C.
Employer identification number (EIN):	364286198
NAIC Classification:	332400