401k Plan data: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN

DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 401k Plan overview

Plan Name	DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED
Plan identification number	515

DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Prepaid legal Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: DAWN FOODS, INC.

Employer identification number (EIN): 380467200

NAIC Classification: 311800
NAIC Description: Bakeries and Tortilla Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
515 2022-01-01
515 2021-01-01
515 2020-01-01
515 2019-01-01
515 2018-01-01
515 2017-01-01
515 2016-01-01
515 2015-01-01
515 2014-01-01
515 2013-01-01
515 2012-01-01 J. BRIAN COLEMAN
515 2011-01-01 J. BRIAN COLEMAN
515 2010-01-01 J. BRIAN COLEMAN
515 2009-01-01 J. BRIAN COLEMAN

Plan Statistics for DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED

401k plan membership statisitcs for DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED

Measure Date Value
2022: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2022 401k membership
Total participants, beginning-of-year 2022-01-01 3,085
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 1,883
Total of all active and inactive participants 2022-01-01 1,883
2021: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,710
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 3,085
Total of all active and inactive participants 2021-01-01 3,085
2020: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2020 401k membership
Total participants, beginning-of-year 2020-01-01 3,591
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,710
Total of all active and inactive participants 2020-01-01 1,710
2019: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2019 401k membership
Total participants, beginning-of-year 2019-01-01 3,712
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 3,591
Total of all active and inactive participants 2019-01-01 3,591
2018: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2018 401k membership
Total participants, beginning-of-year 2018-01-01 2,533
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 3,712
Total of all active and inactive participants 2018-01-01 3,712
2017: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2017 401k membership
Total participants, beginning-of-year 2017-01-01 2,729
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2,533
Total of all active and inactive participants 2017-01-01 2,533
2016: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2016 401k membership
Total participants, beginning-of-year 2016-01-01 2,749
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 2,729
Total of all active and inactive participants 2016-01-01 2,729
2015: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2015 401k membership
Total participants, beginning-of-year 2015-01-01 2,556
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 2,749
Total of all active and inactive participants 2015-01-01 2,749
2014: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2014 401k membership
Total participants, beginning-of-year 2014-01-01 2,521
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 2,556
Total of all active and inactive participants 2014-01-01 2,556
2013: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2013 401k membership
Total participants, beginning-of-year 2013-01-01 2,768
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 2,521
Total of all active and inactive participants 2013-01-01 2,521
2012: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2012 401k membership
Total participants, beginning-of-year 2012-01-01 2,666
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 2,768
Total of all active and inactive participants 2012-01-01 2,768
2011: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2011 401k membership
Total participants, beginning-of-year 2011-01-01 2,903
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 2,666
Total of all active and inactive participants 2011-01-01 2,666
2010: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2010 401k membership
Total participants, beginning-of-year 2010-01-01 2,804
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 2,903
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 2,903
2009: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2009 401k membership
Total participants, beginning-of-year 2009-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 2,804
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 2,804

Measure	Date	Value
2022: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2022 401k membership
Total participants, beginning-of-year	2022-01-01	3,085
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,883
Total of all active and inactive participants	2022-01-01	1,883
2021: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,710
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	3,085
Total of all active and inactive participants	2021-01-01	3,085
2020: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2020 401k membership
Total participants, beginning-of-year	2020-01-01	3,591
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,710
Total of all active and inactive participants	2020-01-01	1,710
2019: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2019 401k membership
Total participants, beginning-of-year	2019-01-01	3,712
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	3,591
Total of all active and inactive participants	2019-01-01	3,591
2018: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,533
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	3,712
Total of all active and inactive participants	2018-01-01	3,712
2017: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2,729
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,533
Total of all active and inactive participants	2017-01-01	2,533
2016: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2016 401k membership
Total participants, beginning-of-year	2016-01-01	2,749
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	2,729
Total of all active and inactive participants	2016-01-01	2,729
2015: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2015 401k membership
Total participants, beginning-of-year	2015-01-01	2,556
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	2,749
Total of all active and inactive participants	2015-01-01	2,749
2014: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2014 401k membership
Total participants, beginning-of-year	2014-01-01	2,521
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	2,556
Total of all active and inactive participants	2014-01-01	2,556
2013: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2013 401k membership
Total participants, beginning-of-year	2013-01-01	2,768
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	2,521
Total of all active and inactive participants	2013-01-01	2,521
2012: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2012 401k membership
Total participants, beginning-of-year	2012-01-01	2,666
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	2,768
Total of all active and inactive participants	2012-01-01	2,768
2011: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2011 401k membership
Total participants, beginning-of-year	2011-01-01	2,903
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	2,666
Total of all active and inactive participants	2011-01-01	2,666
2010: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2010 401k membership
Total participants, beginning-of-year	2010-01-01	2,804
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	2,903
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	2,903
2009: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2009 401k membership
Total participants, beginning-of-year	2009-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	2,804
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	2,804

Form 5500 Responses for DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED

2022: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2010 form 5500 responses
2010-01-01	Type of plan entity	Single 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: DAWN FOOD PRODUCTS, INC. WELFARE BENEFIT PLAN - REVISED 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	First time form 5500 has been submitted	Yes
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

SHD962890

Policy instance

Insurance contract or identification number	SHD962890
Number of Individuals Covered	1883
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

0000159358

Policy instance

Insurance contract or identification number	0000159358
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 $32
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000158922

Policy instance

Insurance contract or identification number	0000158922
Number of Individuals Covered	41
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,971
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,971
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BCS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 38245 )

Policy contract number

ESL-30386

Policy instance

Insurance contract or identification number	ESL-30386
Number of Individuals Covered	1354
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $26,009
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $743,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,009
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

SA2-890-LF0737

Policy instance

Insurance contract or identification number	SA2-890-LF0737
Number of Individuals Covered	1748
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $93,686
Total amount of fees paid to insurance company	USD $41,193
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $818,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93,686
Amount paid for insurance broker fees	41193
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GF2-890-LF0737

Policy instance

Insurance contract or identification number	GF2-890-LF0737
Number of Individuals Covered	1603
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,825
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $291,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,825
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

PD2-890-LF0737

Policy instance

Insurance contract or identification number	PD2-890-LF0737
Number of Individuals Covered	1950
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
Other welfare benefits provided	LEAVE SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $34,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

PD2-890-LF0737

Policy instance

Insurance contract or identification number	PD2-890-LF0737
Number of Individuals Covered	1603
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
Temporary Disability 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

R0147637

Policy instance

Insurance contract or identification number	R0147637
Number of Individuals Covered	4
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $100
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $1,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000159356

Policy instance

Insurance contract or identification number	0000159356
Number of Individuals Covered	5
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $86
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $86
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

LK965126

Policy instance

Insurance contract or identification number	LK965126
Number of Individuals Covered	1883
Insurance policy start date	2022-01-01
Insurance policy end date	2022-05-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $11,539
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-28,400
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	11539
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD075450

Policy instance

Insurance contract or identification number	NYD075450
Number of Individuals Covered	7
Insurance policy start date	2022-01-01
Insurance policy end date	2022-06-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $50
Temporary 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 $0
Amount paid for insurance broker fees	50
Insurance broker organization code?	3

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

Policy contract number

R0147637

Policy instance

Insurance contract or identification number	R0147637
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 & CRITICAL ILLNESS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000159356

Policy instance

Insurance contract or identification number	0000159356
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
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD075450

Policy instance

Insurance contract or identification number	NYD075450
Number of Individuals Covered	6
Insurance policy start date	2021-03-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $178
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $178
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

LK965126

Policy instance

Insurance contract or identification number	LK965126
Number of Individuals Covered	1554
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,839
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $239,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,839
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

159358

Policy instance

Insurance contract or identification number	159358
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
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000158922

Policy instance

Insurance contract or identification number	0000158922
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
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

SHD962890

Policy instance

Insurance contract or identification number	SHD962890
Number of Individuals Covered	1554
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

278595

Policy instance

Insurance contract or identification number	278595
Number of Individuals Covered	3085
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $21,514
Total amount of fees paid to insurance company	USD $118,173
Welfare Benefit Premiums Paid to Carrier	USD $614,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,514
Amount paid for insurance broker fees	118173
Insurance broker organization code?	3

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

Policy contract number

R0147637

Policy instance

Insurance contract or identification number	R0147637
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $115
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $1,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $86
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000159356

Policy instance

Insurance contract or identification number	0000159356
Number of Individuals Covered	6
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $252
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $252
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD075450

Policy instance

Insurance contract or identification number	NYD075450
Number of Individuals Covered	0
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 $507
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-9,737
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	507
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3

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

Policy contract number

LK965126

Policy instance

Insurance contract or identification number	LK965126
Number of Individuals Covered	1669
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,950
Total amount of fees paid to insurance company	USD $11,268
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $628,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,950
Amount paid for insurance broker fees	11268
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

159358

Policy instance

Insurance contract or identification number	159358
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $39
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000158922

Policy instance

Insurance contract or identification number	0000158922
Number of Individuals Covered	60
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,306
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,306
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

70470-9

Policy instance

Insurance contract or identification number	70470-9
Number of Individuals Covered	1710
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $152,728
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,554,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $152,728
Additional information about fees paid to insurance broker	WRITING AGENT
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	261
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,234
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $60,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,234
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000159356

Policy instance

Insurance contract or identification number	0000159356
Number of Individuals Covered	7
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $306
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $306
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

EXRK

Policy instance

Insurance contract or identification number	EXRK
Number of Individuals Covered	1983
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $58,532
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $808,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,532
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	WRITING AGENT
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD075450

Policy instance

Insurance contract or identification number	NYD075450
Number of Individuals Covered	7
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,266
Total amount of fees paid to insurance company	USD $11
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,266
Amount paid for insurance broker fees	11
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3

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

Policy contract number

LK965126

Policy instance

Insurance contract or identification number	LK965126
Number of Individuals Covered	2357
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,278
Total amount of fees paid to insurance company	USD $8,313
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $593,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,278
Amount paid for insurance broker fees	8313
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3

SECURIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93742 )

Policy contract number

70260

Policy instance

Insurance contract or identification number	70260
Number of Individuals Covered	3591
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $120,835
Total amount of fees paid to insurance company	USD $22,003
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $965,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $120,835
Amount paid for insurance broker fees	22003
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

159358

Policy instance

Insurance contract or identification number	159358
Number of Individuals Covered	2
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $45
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000158922

Policy instance

Insurance contract or identification number	0000158922
Number of Individuals Covered	68
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,328
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,328
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

R0147637

Policy instance

Insurance contract or identification number	R0147637
Number of Individuals Covered	5
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $118
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $1,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $88
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000159356

Policy instance

Insurance contract or identification number	0000159356
Number of Individuals Covered	7
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $356
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $356
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

R0147637

Policy instance

Insurance contract or identification number	R0147637
Number of Individuals Covered	5
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $123
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $1,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $92
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

LK965126

Policy instance

Insurance contract or identification number	LK965126
Number of Individuals Covered	2466
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $11,588
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $609,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,588
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

SECURIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93742 )

Policy contract number

70260

Policy instance

Insurance contract or identification number	70260
Number of Individuals Covered	3712
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $128,060
Total amount of fees paid to insurance company	USD $23,154
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,020,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $128,060
Amount paid for insurance broker fees	23154
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMISSIONS
Insurance broker organization code?	3

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

Policy contract number

FML962890

Policy instance

Insurance contract or identification number	FML962890
Number of Individuals Covered	2470
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 $5,960
Temporary 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 $0
Amount paid for insurance broker fees	5960
Insurance broker organization code?	3

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0000158922

Policy instance

Insurance contract or identification number	0000158922
Number of Individuals Covered	77
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,398
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,398
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

EXRK

Policy instance

Insurance contract or identification number	EXRK
Number of Individuals Covered	2027
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $58,993
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $733,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,993
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	WRITING AGENT & SUPP COMPENSATION
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD075450

Policy instance

Insurance contract or identification number	NYD075450
Number of Individuals Covered	8
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $107
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $107
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	244
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,153
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $47,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,153
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 )

Policy contract number

159358

Policy instance

Insurance contract or identification number	159358
Number of Individuals Covered	3
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $90
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $90
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	245
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,011
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $50,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,011
Insurance broker organization code?	3
Insurance broker name	THE RICHMOND AGENCY, INC.

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

Policy contract number

R0147637

Policy instance

Insurance contract or identification number	R0147637
Number of Individuals Covered	5
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $123
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $92
Insurance broker organization code?	3
Insurance broker name	MORRIS, CHRISTOPHER ROBERT

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0010750957

Policy instance

Insurance contract or identification number	0010750957
Number of Individuals Covered	475
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $22,889
Total amount of fees paid to insurance company	USD $102
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,669
Insurance broker organization code?	3
Amount paid for insurance broker fees	102
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker name	HODGES-MACE BENEFITS GRP INC

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD075450

Policy instance

Insurance contract or identification number	NYD075450
Number of Individuals Covered	2533
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $43
Total amount of fees paid to insurance company	USD $20
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43
Amount paid for insurance broker fees	20
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

LK965126

Policy instance

Insurance contract or identification number	LK965126
Number of Individuals Covered	2512
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $12,616
Total amount of fees paid to insurance company	USD $23,688
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $655,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,616
Amount paid for insurance broker fees	23688
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

SECURIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93742 )

Policy contract number

70260

Policy instance

Insurance contract or identification number	70260
Number of Individuals Covered	3894
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $127,715
Total amount of fees paid to insurance company	USD $22,848
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,016,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $127,715
Amount paid for insurance broker fees	22848
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

247433

Policy instance

Insurance contract or identification number	247433
Number of Individuals Covered	2127
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $36,339
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $726,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,339
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	256
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,930
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $55,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,930
Insurance broker organization code?	3
Insurance broker name	THE RICHMOND AGENCY, INC.

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

Policy contract number

51332-1

Policy instance

Insurance contract or identification number	51332-1
Number of Individuals Covered	2749
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $182,200
Total amount of fees paid to insurance company	USD $3,106
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,536,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $182,200
Amount paid for insurance broker fees	3106
Additional information about fees paid to insurance broker	PRINTING SERVICES
Insurance broker name	HARVARD PRINTING GROUP

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

Policy contract number

R0147637

Policy instance

Insurance contract or identification number	R0147637
Number of Individuals Covered	7
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $203
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $152
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER MORRIS

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008525452

Policy instance

Insurance contract or identification number	0008525452
Number of Individuals Covered	840
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $9,980
Total amount of fees paid to insurance company	USD $476
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $25,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,502
Amount paid for insurance broker fees	476
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	RICHMOND AGENCY

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

Policy contract number

51332-1

Policy instance

Insurance contract or identification number	51332-1
Number of Individuals Covered	2556
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $114,279
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,269,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $114,279
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	218
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,151
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	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $33,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,151
Insurance broker organization code?	3
Insurance broker name	THE RICHMOND AGENCY, INC.

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

Policy contract number

R0147637

Policy instance

Insurance contract or identification number	R0147637
Number of Individuals Covered	1620
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $28,104
Total amount of fees paid to insurance company	USD $5,179
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
Welfare Benefit Premiums Paid to Carrier	USD $74,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,135
Amount paid for insurance broker fees	5051
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER MORRIS

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008525452

Policy instance

Insurance contract or identification number	0008525452
Number of Individuals Covered	2083
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $86,834
Total amount of fees paid to insurance company	USD $6,166
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $277,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,515
Amount paid for insurance broker fees	6145
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	RICHMOND AGENCY

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

0008525452

Policy instance

Insurance contract or identification number	0008525452
Number of Individuals Covered	4
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $45
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
Welfare Benefit Premiums Paid to Carrier	USD $84
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER MORRIS

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

47080

Policy instance

Insurance contract or identification number	47080
Number of Individuals Covered	234
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,116
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	IDENTITY THEFT PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $42,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,015
Insurance broker organization code?	4
Insurance broker name	VIETTE & ASSOCIATES INC

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

Policy contract number

R0147637

Policy instance

Insurance contract or identification number	R0147637
Number of Individuals Covered	1869
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $167,689
Total amount of fees paid to insurance company	USD $30,944
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
Welfare Benefit Premiums Paid to Carrier	USD $441,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $126,113
Amount paid for insurance broker fees	30197
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER MORRIS

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	150
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,204
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	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $35,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,204
Insurance broker organization code?	3
Insurance broker name	THE RICHMOND AGENCY, INC.

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

Policy contract number

51332-1

Policy instance

Insurance contract or identification number	51332-1
Number of Individuals Covered	2521
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $141,018
Total amount of fees paid to insurance company	USD $598
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,395,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $111,018
Insurance broker organization code?	3
Amount paid for insurance broker fees	598
Additional information about fees paid to insurance broker	PRINTING SERVICES
Insurance broker name	HARVARD PRINTING GROUP

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

47080

Policy instance

Insurance contract or identification number	47080
Number of Individuals Covered	231
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,518
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	IDENTITY THEFT PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $35,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,843
Insurance broker organization code?	4
Insurance broker name	VIETTE & ASSOCIATES INC

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

0008525452

Policy instance

Insurance contract or identification number	0008525452
Number of Individuals Covered	4
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $555
Total amount of fees paid to insurance company	USD $32
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
Welfare Benefit Premiums Paid to Carrier	USD $1,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $417
Amount paid for insurance broker fees	32
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER R MORRIS

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008525452

Policy instance

Insurance contract or identification number	0008525452
Number of Individuals Covered	2340
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $205,337
Total amount of fees paid to insurance company	USD $25,083
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $496,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $155,887
Amount paid for insurance broker fees	24773
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	RICHMOND AGENCY INC

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	183
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,764
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	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $31,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,764
Insurance broker organization code?	3
Insurance broker name	THE RICHMOND AGENCY, INC.

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

Policy contract number

51332-1

Policy instance

Insurance contract or identification number	51332-1
Number of Individuals Covered	2744
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $101,240
Total amount of fees paid to insurance company	USD $2,157
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,424,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $101,240
Insurance broker organization code?	3
Amount paid for insurance broker fees	2157
Additional information about fees paid to insurance broker	PRINTING SERVICES
Insurance broker name	HARVARD PRINTING GROUP

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0008525452

Policy instance

Insurance contract or identification number	0008525452
Number of Individuals Covered	1460
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $189,280
Total amount of fees paid to insurance company	USD $26,619
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	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $330,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	189
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,696
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	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $41,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010065773

Policy instance

Insurance contract or identification number	000010065773
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $13,849
Total amount of fees paid to insurance company	USD $8,750
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 $980,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010065772

Policy instance

Insurance contract or identification number	000010065772
Number of Individuals Covered	2666
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $92,823
Total amount of fees paid to insurance company	USD $17,500
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 & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $937,259
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

0008525452

Policy instance

Insurance contract or identification number	0008525452
Number of Individuals Covered	409
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $69,949
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 $99,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

0008525452

Policy instance

Insurance contract or identification number	0008525452
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $118
Total amount of fees paid to insurance company	USD $8
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
Welfare Benefit Premiums Paid to Carrier	USD $181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

47080

Policy instance

Insurance contract or identification number	47080
Number of Individuals Covered	170
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11,859
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	IDENTITY THEFT PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $25,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1500783

Policy instance

Insurance contract or identification number	1500783
Number of Individuals Covered	141
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,808
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	PREPAID LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $25,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010065773

Policy instance

Insurance contract or identification number	000010065773
Number of Individuals Covered	2412
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,572
Total amount of fees paid to insurance company	USD $7,423
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 $808,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000010065772

Policy instance

Insurance contract or identification number	000010065772
Number of Individuals Covered	2903
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $25,589
Total amount of fees paid to insurance company	USD $14,847
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 & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $977,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

DAWN FOODS PUERTO RICO SAVINGS PLAN [EIN = 660234708]

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Company Name:	DAWN FOODS, INC.
Employer identification number (EIN):	380467200
NAIC Classification:	311800
NAIC Description:	Bakeries and Tortilla Manufacturing