401k Plan data: BISSELL ASSOCIATE BENEFIT PLAN plan

BISSELL ASSOCIATE BENEFIT PLAN 401k Plan overview

Plan Name	BISSELL ASSOCIATE BENEFIT PLAN
Plan identification number	502

BISSELL ASSOCIATE 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) Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: BISSELL, INC.

Employer identification number (EIN): 380352410

NAIC Classification: 332900

Additional information about BISSELL, INC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 1998-03-30

Company Identification Number: 0012025506

Legal Registered Office Address: PO BOX 1888

GRAND RAPIDS
United States of America (USA)
49501

More information about BISSELL, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BISSELL ASSOCIATE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2023-01-01 KEVIN LITTLE 2024-07-24
502 2022-01-01 KEVIN LITTLE 2023-07-17
502 2021-01-01 KEVIN LITTLE 2022-07-27
502 2020-01-01 KEVIN LITTLE 2021-06-03
502 2019-01-01 KEVIN LITTLE 2020-07-13
502 2018-01-01 KEVIN LITTLE 2019-10-07
502 2017-01-01
502 2017-01-01
502 2016-01-01
502 2015-01-01
502 2014-01-01
502 2013-01-01
502 2012-01-01 KATHY SYLVESTER
502 2011-01-01 KATHY SYLVESTER
502 2010-01-01 COLLEEN SCALF
502 2009-01-01 COLLEEN SCALF

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
502	2023-01-01	KEVIN LITTLE	2024-07-24
502	2022-01-01	KEVIN LITTLE	2023-07-17
502	2021-01-01	KEVIN LITTLE	2022-07-27
502	2020-01-01	KEVIN LITTLE	2021-06-03
502	2019-01-01	KEVIN LITTLE	2020-07-13
502	2018-01-01	KEVIN LITTLE	2019-10-07
502	2017-01-01
502	2017-01-01
502	2016-01-01
502	2015-01-01
502	2014-01-01
502	2013-01-01
502	2012-01-01	KATHY SYLVESTER
502	2011-01-01	KATHY SYLVESTER
502	2010-01-01	COLLEEN SCALF
502	2009-01-01	COLLEEN SCALF

Plan Statistics for BISSELL ASSOCIATE BENEFIT PLAN

401k plan membership statisitcs for BISSELL ASSOCIATE BENEFIT PLAN

Measure Date Value
2023: BISSELL ASSOCIATE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 751
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 737
Number of retired or separated participants receiving benefits 2023-01-01 14
Total of all active and inactive participants 2023-01-01 751
2022: BISSELL ASSOCIATE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 834
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 734
Number of retired or separated participants receiving benefits 2022-01-01 17
Total of all active and inactive participants 2022-01-01 751
2021: BISSELL ASSOCIATE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 622
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 812
Number of retired or separated participants receiving benefits 2021-01-01 22
Total of all active and inactive participants 2021-01-01 834
2020: BISSELL ASSOCIATE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 570
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 598
Number of retired or separated participants receiving benefits 2020-01-01 24
Total of all active and inactive participants 2020-01-01 622
2019: BISSELL ASSOCIATE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 512
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 544
Number of retired or separated participants receiving benefits 2019-01-01 26
Total of all active and inactive participants 2019-01-01 570
2018: BISSELL ASSOCIATE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 450
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 492
Number of retired or separated participants receiving benefits 2018-01-01 20
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 512
2017: BISSELL ASSOCIATE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 428
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 424
Number of retired or separated participants receiving benefits 2017-01-01 26
Total of all active and inactive participants 2017-01-01 450
2016: BISSELL ASSOCIATE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 396
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 395
Number of retired or separated participants receiving benefits 2016-01-01 33
Total of all active and inactive participants 2016-01-01 428
2015: BISSELL ASSOCIATE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 408
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 396
Number of retired or separated participants receiving benefits 2015-01-01 32
Total of all active and inactive participants 2015-01-01 428
2014: BISSELL ASSOCIATE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 453
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 370
Number of retired or separated participants receiving benefits 2014-01-01 38
Total of all active and inactive participants 2014-01-01 408
2013: BISSELL ASSOCIATE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 484
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 386
Number of retired or separated participants receiving benefits 2013-01-01 67
Total of all active and inactive participants 2013-01-01 453
2012: BISSELL ASSOCIATE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 454
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 413
Number of retired or separated participants receiving benefits 2012-01-01 71
Total of all active and inactive participants 2012-01-01 484
2011: BISSELL ASSOCIATE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 451
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 381
Number of retired or separated participants receiving benefits 2011-01-01 73
Total of all active and inactive participants 2011-01-01 454
2010: BISSELL ASSOCIATE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 421
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 374
Number of retired or separated participants receiving benefits 2010-01-01 77
Total of all active and inactive participants 2010-01-01 451
2009: BISSELL ASSOCIATE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 407
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 348
Number of retired or separated participants receiving benefits 2009-01-01 73
Total of all active and inactive participants 2009-01-01 421

Measure	Date	Value
2023: BISSELL ASSOCIATE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	751
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	737
Number of retired or separated participants receiving benefits	2023-01-01	14
Total of all active and inactive participants	2023-01-01	751
2022: BISSELL ASSOCIATE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	834
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	734
Number of retired or separated participants receiving benefits	2022-01-01	17
Total of all active and inactive participants	2022-01-01	751
2021: BISSELL ASSOCIATE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	622
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	812
Number of retired or separated participants receiving benefits	2021-01-01	22
Total of all active and inactive participants	2021-01-01	834
2020: BISSELL ASSOCIATE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	570
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	598
Number of retired or separated participants receiving benefits	2020-01-01	24
Total of all active and inactive participants	2020-01-01	622
2019: BISSELL ASSOCIATE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	512
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	544
Number of retired or separated participants receiving benefits	2019-01-01	26
Total of all active and inactive participants	2019-01-01	570
2018: BISSELL ASSOCIATE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	450
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	492
Number of retired or separated participants receiving benefits	2018-01-01	20
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	512
2017: BISSELL ASSOCIATE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	428
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	424
Number of retired or separated participants receiving benefits	2017-01-01	26
Total of all active and inactive participants	2017-01-01	450
2016: BISSELL ASSOCIATE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	396
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	395
Number of retired or separated participants receiving benefits	2016-01-01	33
Total of all active and inactive participants	2016-01-01	428
2015: BISSELL ASSOCIATE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	408
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	396
Number of retired or separated participants receiving benefits	2015-01-01	32
Total of all active and inactive participants	2015-01-01	428
2014: BISSELL ASSOCIATE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	453
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	370
Number of retired or separated participants receiving benefits	2014-01-01	38
Total of all active and inactive participants	2014-01-01	408
2013: BISSELL ASSOCIATE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	484
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	386
Number of retired or separated participants receiving benefits	2013-01-01	67
Total of all active and inactive participants	2013-01-01	453
2012: BISSELL ASSOCIATE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	454
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	413
Number of retired or separated participants receiving benefits	2012-01-01	71
Total of all active and inactive participants	2012-01-01	484
2011: BISSELL ASSOCIATE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	451
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	381
Number of retired or separated participants receiving benefits	2011-01-01	73
Total of all active and inactive participants	2011-01-01	454
2010: BISSELL ASSOCIATE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	421
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	374
Number of retired or separated participants receiving benefits	2010-01-01	77
Total of all active and inactive participants	2010-01-01	451
2009: BISSELL ASSOCIATE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	407
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	348
Number of retired or separated participants receiving benefits	2009-01-01	73
Total of all active and inactive participants	2009-01-01	421

Form 5500 Responses for BISSELL ASSOCIATE BENEFIT PLAN

2023: BISSELL ASSOCIATE BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: BISSELL ASSOCIATE 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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: BISSELL ASSOCIATE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Mulitple employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: BISSELL ASSOCIATE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Mulitple employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: BISSELL ASSOCIATE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Mulitple employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: BISSELL ASSOCIATE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Mulitple employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: BISSELL ASSOCIATE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Mulitple employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

SHD0962379

Policy instance

Insurance contract or identification number	SHD0962379
Number of Individuals Covered	870
Insurance policy start date	2022-08-01
Insurance policy end date	2023-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ADMINISTRATIVE SERVICE ONLY
Welfare Benefit Premiums Paid to Carrier	USD $23,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	870
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $11,371
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $227,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	870
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,885
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,461
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

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	544
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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
Welfare Benefit Premiums Paid to Carrier	USD $97,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	126
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT FOR BUSINESS TRAVEL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	870
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $486
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $9,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	1
Insurance policy start date	2022-03-01
Insurance policy end date	2023-02-28
Total amount of commissions paid to insurance broker	USD $489
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $4,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0010446

Policy instance

Insurance contract or identification number	0010446
Number of Individuals Covered	704
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $940
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA BEHAVIORAL HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

5127

Policy instance

Insurance contract or identification number	5127
Number of Individuals Covered	870
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $11,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )

Policy contract number

798172

Policy instance

Insurance contract or identification number	798172
Number of Individuals Covered	751
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $25,704
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	878
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $15,680
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $313,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,680
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	878
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,706
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $170,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,706
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	556
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $106,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	192
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,574
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT FOR BUSINESS TRAVEL
Welfare Benefit Premiums Paid to Carrier	USD $15,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,574
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	878
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $691
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $13,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $691
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,682
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $16,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,682
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

75369

Policy instance

Insurance contract or identification number	75369
Number of Individuals Covered	751
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $38,294
Total amount of fees paid to insurance company	USD $621,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	589185
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $38,294

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0010446

Policy instance

Insurance contract or identification number	0010446
Number of Individuals Covered	697
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 $11,400
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 $0
Amount paid for insurance broker fees	11400
Insurance broker organization code?	3

CIGNA BEHAVIORAL HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

5127

Policy instance

Insurance contract or identification number	5127
Number of Individuals Covered	878
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $10,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	925
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,865
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $157,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,865
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	925
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,316
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,316
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	580
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	123
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
Other welfare benefits provided	ACCIDENT FOR BUSINESS TRAVEL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	925
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $331
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $6,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $331
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	1
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $1,815
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $18,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,815
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

75369

Policy instance

Insurance contract or identification number	75369
Number of Individuals Covered	834
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $34,919
Total amount of fees paid to insurance company	USD $563,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	534335
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $34,919

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

0010446

Policy instance

Insurance contract or identification number	0010446
Number of Individuals Covered	742
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
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 $0
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA BEHAVIORAL HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

5127

Policy instance

Insurance contract or identification number	5127
Number of Individuals Covered	925
Insurance policy start date	2020-06-01
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
Other welfare benefits provided	EMPLOYEE ASSISTANCE PLAN
Welfare Benefit Premiums Paid to Carrier	USD $10,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	745
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $8,520
Total amount of fees paid to insurance company	USD $4,856
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $170,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,520
Amount paid for insurance broker fees	4856
Insurance broker organization code?	3

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	745
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $4,987
Total amount of fees paid to insurance company	USD $2,955
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $98,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,987
Amount paid for insurance broker fees	2955
Insurance broker organization code?	3

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	450
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
Welfare Benefit Premiums Paid to Carrier	USD $76,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	130
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $165
Other welfare benefits provided	ACCIDENT FOR BUSINESS TRAVEL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	165
Insurance broker organization code?	3

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	745
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $330
Total amount of fees paid to insurance company	USD $200
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $6,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $330
Amount paid for insurance broker fees	200
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	1
Insurance policy start date	2020-03-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $1,815
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $18,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,815
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

75369

Policy instance

Insurance contract or identification number	75369
Number of Individuals Covered	622
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $37,022
Total amount of fees paid to insurance company	USD $509,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	477018
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATOR
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $37,022

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

75369

Policy instance

Insurance contract or identification number	75369
Number of Individuals Covered	570
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $16,997
Total amount of fees paid to insurance company	USD $409,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	380545
Additional information about fees paid to insurance broker	THIRD PARTY ADMINISTRATION
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $16,997

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	604
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $1,727
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $17,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,727
Insurance broker organization code?	3

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $424
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $8,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $424
Insurance broker organization code?	3

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	331
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $2,291
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT FOR BUSINESS TRAVEL
Welfare Benefit Premiums Paid to Carrier	USD $15,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,291
Insurance broker organization code?	3

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	374
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
Welfare Benefit Premiums Paid to Carrier	USD $69,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	604
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $5,181
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,181
Insurance broker organization code?	3

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	604
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $10,725
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $214,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,725
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

75369

Policy instance

Insurance contract or identification number	75369
Number of Individuals Covered	512
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $26,423
Total amount of fees paid to insurance company	USD $347,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	315445
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $26,423

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	554
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $1,727
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $17,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,727
Insurance broker organization code?	3

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	554
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $535
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $4,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $535
Insurance broker organization code?	3

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	554
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $849
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT FOR BUSINESS TRAVEL
Welfare Benefit Premiums Paid to Carrier	USD $5,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $849
Insurance broker organization code?	3

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	347
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
Welfare Benefit Premiums Paid to Carrier	USD $59,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	554
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $4,467
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,467
Insurance broker organization code?	3

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	554
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $5,754
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,754
Insurance broker organization code?	3

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	499
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $7,346
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,346
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	499
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $4,833
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,833
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	300
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
Welfare Benefit Premiums Paid to Carrier	USD $52,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	499
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $886
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT FOR BUSINESS TRAVEL
Welfare Benefit Premiums Paid to Carrier	USD $5,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $886
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

75369

Policy instance

Insurance contract or identification number	75369
Number of Individuals Covered	450
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $16,635
Total amount of fees paid to insurance company	USD $352,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	320189
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $16,635
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	499
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $17,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	499
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $255
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $5,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $255
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	423
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $886
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT FOR BUSINESS TRAVEL
Welfare Benefit Premiums Paid to Carrier	USD $5,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $886
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	423
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $5,681
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $113,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,681
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	247
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
Welfare Benefit Premiums Paid to Carrier	USD $42,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	423
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $206
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $4,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $206
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	1
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $917
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $9,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $917
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

75369

Policy instance

Insurance contract or identification number	75369
Number of Individuals Covered	428
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,538
Total amount of fees paid to insurance company	USD $308,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	271725
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $10,538
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	423
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $4,458
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,458
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	254
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,592
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 $38,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,592
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

OK967350

Policy instance

Insurance contract or identification number	OK967350
Number of Individuals Covered	403
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $201
Total amount of fees paid to insurance company	USD $67
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	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $4,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $201
Amount paid for insurance broker fees	67
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	1
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $917
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	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $9,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $917
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

75369

Policy instance

Insurance contract or identification number	75369
Number of Individuals Covered	444
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,016
Total amount of fees paid to insurance company	USD $25,291
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $236,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,016
Amount paid for insurance broker fees	25291
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC.

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

Policy contract number

LK964001

Policy instance

Insurance contract or identification number	LK964001
Number of Individuals Covered	403
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $4,347
Total amount of fees paid to insurance company	USD $770
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 $46,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,347
Amount paid for insurance broker fees	770
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	425
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,071
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	ACCIDENT FOR BUSINESS TRAVEL
Welfare Benefit Premiums Paid to Carrier	USD $7,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,071
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

FLX965783

Policy instance

Insurance contract or identification number	FLX965783
Number of Individuals Covered	403
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $5,625
Total amount of fees paid to insurance company	USD $1,998
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 $112,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,625
Amount paid for insurance broker fees	1998
Additional information about fees paid to insurance broker	SALES & SERVICES
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

CIGNA HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	453
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $917
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	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $9,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $917
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	258
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,763
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 $45,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,763
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148523

Policy instance

Insurance contract or identification number	148523
Number of Individuals Covered	422
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,216
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,216
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	453
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,071
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	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $7,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,071
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148523

Policy instance

Insurance contract or identification number	148523
Number of Individuals Covered	422
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,433
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,433
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148523

Policy instance

Insurance contract or identification number	148523
Number of Individuals Covered	454
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,089
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,089
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148523

Policy instance

Insurance contract or identification number	148523
Number of Individuals Covered	454
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,479
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,479
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	258
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,684
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,684
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )

Policy contract number

04998A

Policy instance

Insurance contract or identification number	04998A
Number of Individuals Covered	484
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $714
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	MEDICAL BENEFITS ABROAD COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $7,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $714
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Number of Individuals Covered	484
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,071
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	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $7,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,071
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

30023276

Policy instance

Insurance contract or identification number	30023276
Number of Individuals Covered	227
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,558
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 $36,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ABL647238

Policy instance

Insurance contract or identification number	ABL647238
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148523

Policy instance

Insurance contract or identification number	148523
Number of Individuals Covered	432
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,448
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148523

Policy instance

Insurance contract or identification number	148523
Number of Individuals Covered	432
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,296
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148523

Policy instance

Insurance contract or identification number	148523
Number of Individuals Covered	423
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $5,304
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,304
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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

Policy contract number

9770546

Policy instance

Insurance contract or identification number	9770546
Number of Individuals Covered	514
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,266
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 $24,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,266
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148523

Policy instance

Insurance contract or identification number	148523
Number of Individuals Covered	423
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $7,462
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,462
Insurance broker organization code?	3
Insurance broker name	ADVANTAGE BENEFITS GROUP INC

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Company Name:	BISSELL, INC.
Employer identification number (EIN):	380352410
NAIC Classification:	332900

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	1998-03-30
Company Identification Number:	0012025506
Legal Registered Office Address:	PO BOX 1888 GRAND RAPIDS United States of America (USA) 49501