401k Plan data: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT plan

EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 401k Plan overview

Plan Name	EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT
Plan identification number	506

EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 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

EBY-BROWN COMPANY, LLC has sponsored the creation of one or more 401k plans.

Company Name: EBY-BROWN COMPANY, LLC

Employer identification number (EIN): 364382177

NAIC Classification: 424940
NAIC Description: Tobacco and Tobacco Product Merchant Wholesalers

Additional information about EBY-BROWN COMPANY, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 3240751

More information about EBY-BROWN COMPANY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2020-01-01 BONNIE CHLEBEK 2021-10-12 BONNIE CHLEBEK 2021-10-12
506 2020-01-01
506 2019-01-01
506 2018-01-01 BONNIE CHLEBEK 2019-10-07 BONNIE CHLEBEK 2019-10-07
506 2017-01-01
506 2016-01-01
506 2016-01-01 BONNIE CHLEBEK 2017-10-12
506 2015-01-01
506 2014-01-01
506 2013-01-01
506 2012-01-01 GARY SKARR

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
506	2020-01-01	BONNIE CHLEBEK	2021-10-12	BONNIE CHLEBEK	2021-10-12
506	2020-01-01
506	2019-01-01
506	2018-01-01	BONNIE CHLEBEK	2019-10-07	BONNIE CHLEBEK	2019-10-07
506	2017-01-01
506	2016-01-01
506	2016-01-01	BONNIE CHLEBEK	2017-10-12
506	2015-01-01
506	2014-01-01
506	2013-01-01
506	2012-01-01	GARY SKARR

Plan Statistics for EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT

401k plan membership statisitcs for EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT

Measure Date Value
2020: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2020 401k membership
Total participants, beginning-of-year 2020-01-01 1,959
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,798
Total of all active and inactive participants 2020-01-01 1,798
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
2019: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2019 401k membership
Total participants, beginning-of-year 2019-01-01 2,104
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,959
Total of all active and inactive participants 2019-01-01 1,959
2018: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2018 401k membership
Total participants, beginning-of-year 2018-01-01 2,096
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 2,104
Total of all active and inactive participants 2018-01-01 2,104
2017: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2017 401k membership
Total participants, beginning-of-year 2017-01-01 2,012
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2,096
Total of all active and inactive participants 2017-01-01 2,096
2016: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,869
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 2,012
Total of all active and inactive participants 2016-01-01 2,012
2015: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,755
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,869
Total of all active and inactive participants 2015-01-01 1,869
2014: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,909
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,755
Total of all active and inactive participants 2014-01-01 1,755
2013: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2013 401k membership
Total participants, beginning-of-year 2013-01-01 2,293
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,909
Total of all active and inactive participants 2013-01-01 1,909
2012: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2012 401k membership
Total participants, beginning-of-year 2012-01-01 2,599
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 2,293
Total of all active and inactive participants 2012-01-01 2,293

Measure	Date	Value
2020: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,959
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,798
Total of all active and inactive participants	2020-01-01	1,798
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
2019: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2019 401k membership
Total participants, beginning-of-year	2019-01-01	2,104
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,959
Total of all active and inactive participants	2019-01-01	1,959
2018: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,096
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,104
Total of all active and inactive participants	2018-01-01	2,104
2017: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2,012
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,096
Total of all active and inactive participants	2017-01-01	2,096
2016: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,869
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	2,012
Total of all active and inactive participants	2016-01-01	2,012
2015: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,755
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,869
Total of all active and inactive participants	2015-01-01	1,869
2014: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,909
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,755
Total of all active and inactive participants	2014-01-01	1,755
2013: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2013 401k membership
Total participants, beginning-of-year	2013-01-01	2,293
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,909
Total of all active and inactive participants	2013-01-01	1,909
2012: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2012 401k membership
Total participants, beginning-of-year	2012-01-01	2,599
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	2,293
Total of all active and inactive participants	2012-01-01	2,293

Form 5500 Responses for EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT

2020: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
2020-01-01	This submission is the final filing	Yes
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 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: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 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: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 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: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	Yes
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 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: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 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: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 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: EBY-BROWN CO., LLC EMPLOYEE WELFARE BENEFIT 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

E4599585

Policy instance

Insurance contract or identification number	E4599585
Number of Individuals Covered	11
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $210
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $194
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

422832

Policy instance

Insurance contract or identification number	422832
Number of Individuals Covered	484
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $18,522
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $157,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,522
Insurance broker organization code?	4

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

422833

Policy instance

Insurance contract or identification number	422833
Number of Individuals Covered	1798
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $56,948
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $484,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,948
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20029

Policy instance

Insurance contract or identification number	20029
Number of Individuals Covered	1375
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $556,337
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: 12516 )

Policy contract number

12001436

Policy instance

Insurance contract or identification number	12001436
Number of Individuals Covered	1298
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
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

422832

Policy instance

Insurance contract or identification number	422832
Number of Individuals Covered	499
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $14,803
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,803
Insurance broker organization code?	4

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

422833

Policy instance

Insurance contract or identification number	422833
Number of Individuals Covered	1959
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $58,288
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $496,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,288
Insurance broker organization code?	3

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20029

Policy instance

Insurance contract or identification number	20029
Number of Individuals Covered	1453
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $568,672
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: 12516 )

Policy contract number

12001436

Policy instance

Insurance contract or identification number	12001436
Number of Individuals Covered	1402
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
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

E4599585

Policy instance

Insurance contract or identification number	E4599585
Number of Individuals Covered	12
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $202
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,227
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $185
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )

Policy contract number

12001436

Policy instance

Insurance contract or identification number	12001436
Number of Individuals Covered	1366
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20029

Policy instance

Insurance contract or identification number	20029
Number of Individuals Covered	1406
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $540,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

422833

Policy instance

Insurance contract or identification number	422833
Number of Individuals Covered	2104
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $59,313
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $504,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,313
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

422832

Policy instance

Insurance contract or identification number	422832
Number of Individuals Covered	283
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $14,511
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,511
Insurance broker organization code?	3

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

Policy contract number

E4599585

Policy instance

Insurance contract or identification number	E4599585
Number of Individuals Covered	13
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $301
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $253
Insurance broker organization code?	3

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

Policy contract number

E4599585

Policy instance

Insurance contract or identification number	E4599585
Number of Individuals Covered	19
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $435
Total amount of fees paid to insurance company	USD $8
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $349
Amount paid for insurance broker fees	6
Insurance broker organization code?	3
Insurance broker name	WILLIAM E. GOOD

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

021927

Policy instance

Insurance contract or identification number	021927
Number of Individuals Covered	93
Insurance policy start date	2017-11-20
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $19
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19
Insurance broker organization code?	3
Insurance broker name	HENDERSON BROTHERS INC.

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

Policy contract number

0907216

Policy instance

Insurance contract or identification number	0907216
Number of Individuals Covered	56
Insurance policy start date	2017-11-20
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 $1,537
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1537
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	ENGLE-HAMBRIGHT & DAVIES INC.

UNITED CONCORDIA DENTAL PLANS OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 47089 )

Policy contract number

837661-000

Policy instance

Insurance contract or identification number	837661-000
Number of Individuals Covered	38
Insurance policy start date	2017-11-01
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 )

Policy contract number

837661-199

Policy instance

Insurance contract or identification number	837661-199
Number of Individuals Covered	76
Insurance policy start date	2017-11-01
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

422832

Policy instance

Insurance contract or identification number	422832
Number of Individuals Covered	278
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11,601
Total amount of fees paid to insurance company	USD $4,640
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,601
Amount paid for insurance broker fees	4640
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES NATIONAL

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

Policy contract number

0903911

Policy instance

Insurance contract or identification number	0903911
Number of Individuals Covered	269
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,031
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,031
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

422833

Policy instance

Insurance contract or identification number	422833
Number of Individuals Covered	2096
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $49,184
Total amount of fees paid to insurance company	USD $19,673
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $491,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,184
Amount paid for insurance broker fees	19673
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES NATIONAL

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20029

Policy instance

Insurance contract or identification number	20029
Number of Individuals Covered	1567
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $682,265
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: 12516 )

Policy contract number

12001436

Policy instance

Insurance contract or identification number	12001436
Number of Individuals Covered	1500
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
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000VK527

Policy instance

Insurance contract or identification number	000VK527
Number of Individuals Covered	1869
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $48,229
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $482,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,229
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20029

Policy instance

Insurance contract or identification number	20029
Number of Individuals Covered	1438
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $514,391
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: 12516 )

Policy contract number

12001436

Policy instance

Insurance contract or identification number	12001436
Number of Individuals Covered	1465
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
Vision Insurance Welfare Benefit	Yes
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: 12516 )

Policy contract number

12001436

Policy instance

Insurance contract or identification number	12001436
Number of Individuals Covered	1470
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
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20029

Policy instance

Insurance contract or identification number	20029
Number of Individuals Covered	1372
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $525,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000VK527

Policy instance

Insurance contract or identification number	000VK527
Number of Individuals Covered	1755
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $49,075
Total amount of fees paid to insurance company	USD $19,378
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $490,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,075
Amount paid for insurance broker fees	19378
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SERVICES USA

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

Policy contract number

000VK527

Policy instance

Insurance contract or identification number	000VK527
Number of Individuals Covered	1909
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $49,472
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $494,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,472
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SVCS USA INC

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20029

Policy instance

Insurance contract or identification number	20029
Number of Individuals Covered	1481
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $513,468
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: 12516 )

Policy contract number

12001436

Policy instance

Insurance contract or identification number	12001436
Number of Individuals Covered	1744
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
Vision Insurance Welfare Benefit	Yes
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

G000528G

Policy instance

Insurance contract or identification number	G000528G
Number of Individuals Covered	690
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $28,838
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 $212,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,238
Insurance broker organization code?	3
Insurance broker name	MESIROW INSURANCE SERVICES INC

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

Policy contract number

G000528G

Policy instance

Insurance contract or identification number	G000528G
Number of Individuals Covered	142
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,255
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 $50,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,689
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SVCS USA INC

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )

Policy contract number

20029

Policy instance

Insurance contract or identification number	20029
Number of Individuals Covered	1524
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $519,298
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: 12516 )

Policy contract number

12001436

Policy instance

Insurance contract or identification number	12001436
Number of Individuals Covered	2081
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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
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

G000528G

Policy instance

Insurance contract or identification number	G000528G
Number of Individuals Covered	2101
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $16,994
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
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $126,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,493
Insurance broker organization code?	3
Insurance broker name	MESIROW INSURANCE SERVICES INC

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Company Name:	EBY-BROWN COMPANY, LLC
Employer identification number (EIN):	364382177
NAIC Classification:	424940
NAIC Description:	Tobacco and Tobacco Product Merchant Wholesalers

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	3240751