401k Plan data: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN plan

METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN
Plan identification number	501

METROPOLITAN HOSPITAL EMPLOYEE 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 Other welfare benefit cover

401k Sponsoring company profile

UNIVERSITY OF MICHIGAN HEALTH-WEST has sponsored the creation of one or more 401k plans.

Company Name: UNIVERSITY OF MICHIGAN HEALTH-WEST

Employer identification number (EIN): 380593405

NAIC Classification: 622000
NAIC Description: Hospitals

Additional information about UNIVERSITY OF MICHIGAN HEALTH-WEST

Jurisdiction of Incorporation: Michigan Secretary of State

Incorporation Date: 0000-00-00

Company Identification Number: 773062

Legal Registered Office Address: 5900 BYRON CENTER AVE SW WYOMING

United States of America (USA)
49519

More information about UNIVERSITY OF MICHIGAN HEALTH-WEST

Form 5500 Filing Information

Submission information for form 5500 for 401k plan METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 KRIS KURTZ 2023-10-13 KRIS KURTZ 2023-10-13
501 2021-01-01 JAISON GILDNER 2022-10-13 JAISON GILDNER 2022-10-13
501 2020-01-01 BRUCE CARRIER 2021-10-12
501 2019-01-01 JAISON GILDNER 2020-10-13
501 2018-01-01 JAISON GILDNER 2019-10-15
501 2017-01-01
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 ERIKA DUNCAN
501 2011-01-01 ERIKA DUNCAN
501 2010-01-01 FLOYD WILSON
501 2009-01-01 FLOYD WILSON

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	KRIS KURTZ	2023-10-13	KRIS KURTZ	2023-10-13
501	2021-01-01	JAISON GILDNER	2022-10-13	JAISON GILDNER	2022-10-13
501	2020-01-01	BRUCE CARRIER	2021-10-12
501	2019-01-01	JAISON GILDNER	2020-10-13
501	2018-01-01	JAISON GILDNER	2019-10-15
501	2017-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	ERIKA DUNCAN
501	2011-01-01	ERIKA DUNCAN
501	2010-01-01	FLOYD WILSON
501	2009-01-01	FLOYD WILSON

Plan Statistics for METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 2,184
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 2,356
Number of retired or separated participants receiving benefits 2022-01-01 33
Total of all active and inactive participants 2022-01-01 2,389
2021: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 2,181
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 2,170
Number of retired or separated participants receiving benefits 2021-01-01 14
Total of all active and inactive participants 2021-01-01 2,184
2020: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 2,267
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 2,181
Total of all active and inactive participants 2020-01-01 2,181
2019: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 2,217
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 2,257
Number of retired or separated participants receiving benefits 2019-01-01 10
Total of all active and inactive participants 2019-01-01 2,267
2018: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 2,209
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 2,188
Number of retired or separated participants receiving benefits 2018-01-01 29
Total of all active and inactive participants 2018-01-01 2,217
2017: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,979
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2,192
Number of retired or separated participants receiving benefits 2017-01-01 17
Total of all active and inactive participants 2017-01-01 2,209
2016: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,736
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,968
Number of retired or separated participants receiving benefits 2016-01-01 11
Total of all active and inactive participants 2016-01-01 1,979
2015: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,691
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,718
Number of retired or separated participants receiving benefits 2015-01-01 18
Total of all active and inactive participants 2015-01-01 1,736
2014: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,707
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,668
Number of retired or separated participants receiving benefits 2014-01-01 23
Total of all active and inactive participants 2014-01-01 1,691
2013: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,920
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,689
Number of retired or separated participants receiving benefits 2013-01-01 18
Total of all active and inactive participants 2013-01-01 1,707
2012: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,705
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,893
Number of retired or separated participants receiving benefits 2012-01-01 27
Total of all active and inactive participants 2012-01-01 1,920
2011: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 1,669
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 1,688
Number of other retired or separated participants entitled to future benefits 2011-01-01 17
Total of all active and inactive participants 2011-01-01 1,705
2010: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 1,598
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 1,653
Number of other retired or separated participants entitled to future benefits 2010-01-01 16
Total of all active and inactive participants 2010-01-01 1,669
2009: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 1,995
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 1,573
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 25
Total of all active and inactive participants 2009-01-01 1,598

Measure	Date	Value
2022: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	2,184
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	2,356
Number of retired or separated participants receiving benefits	2022-01-01	33
Total of all active and inactive participants	2022-01-01	2,389
2021: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	2,181
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	2,170
Number of retired or separated participants receiving benefits	2021-01-01	14
Total of all active and inactive participants	2021-01-01	2,184
2020: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	2,267
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,181
Total of all active and inactive participants	2020-01-01	2,181
2019: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	2,217
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	2,257
Number of retired or separated participants receiving benefits	2019-01-01	10
Total of all active and inactive participants	2019-01-01	2,267
2018: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,209
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,188
Number of retired or separated participants receiving benefits	2018-01-01	29
Total of all active and inactive participants	2018-01-01	2,217
2017: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,979
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,192
Number of retired or separated participants receiving benefits	2017-01-01	17
Total of all active and inactive participants	2017-01-01	2,209
2016: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,736
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,968
Number of retired or separated participants receiving benefits	2016-01-01	11
Total of all active and inactive participants	2016-01-01	1,979
2015: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,691
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,718
Number of retired or separated participants receiving benefits	2015-01-01	18
Total of all active and inactive participants	2015-01-01	1,736
2014: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,707
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,668
Number of retired or separated participants receiving benefits	2014-01-01	23
Total of all active and inactive participants	2014-01-01	1,691
2013: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,920
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,689
Number of retired or separated participants receiving benefits	2013-01-01	18
Total of all active and inactive participants	2013-01-01	1,707
2012: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,705
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,893
Number of retired or separated participants receiving benefits	2012-01-01	27
Total of all active and inactive participants	2012-01-01	1,920
2011: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	1,669
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	1,688
Number of other retired or separated participants entitled to future benefits	2011-01-01	17
Total of all active and inactive participants	2011-01-01	1,705
2010: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	1,598
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	1,653
Number of other retired or separated participants entitled to future benefits	2010-01-01	16
Total of all active and inactive participants	2010-01-01	1,669
2009: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	1,995
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	1,573
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	25
Total of all active and inactive participants	2009-01-01	1,598

Form 5500 Responses for METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN

2022: METROPOLITAN HOSPITAL EMPLOYEE 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: METROPOLITAN HOSPITAL EMPLOYEE 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: METROPOLITAN HOSPITAL EMPLOYEE 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: METROPOLITAN HOSPITAL EMPLOYEE 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: METROPOLITAN HOSPITAL EMPLOYEE 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: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
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: METROPOLITAN HOSPITAL EMPLOYEE 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: METROPOLITAN HOSPITAL EMPLOYEE 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: METROPOLITAN HOSPITAL EMPLOYEE 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: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan 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: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan 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: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 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: METROPOLITAN HOSPITAL EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single 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

CI 960871

Policy instance

Insurance contract or identification number	CI 960871
Number of Individuals Covered	662
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17,107
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $114,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,107
Insurance broker organization code?	3

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

Policy contract number

OK967035

Policy instance

Insurance contract or identification number	OK967035
Number of Individuals Covered	2147
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $34,000
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $21,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,000
Insurance broker organization code?	7

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

Policy contract number

FLX965455

Policy instance

Insurance contract or identification number	FLX965455
Number of Individuals Covered	2451
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $31,500
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $281,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,500
Insurance broker organization code?	7

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

Policy contract number

LK963785

Policy instance

Insurance contract or identification number	LK963785
Number of Individuals Covered	1413
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $34,000
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $292,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,000
Insurance broker organization code?	7

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

Policy contract number

VDT961408

Policy instance

Insurance contract or identification number	VDT961408
Number of Individuals Covered	613
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $31,500
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,500
Insurance broker organization code?	7

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

Policy contract number

AI 960904

Policy instance

Insurance contract or identification number	AI 960904
Number of Individuals Covered	388
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $13,595
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $90,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,595
Insurance broker organization code?	3

ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )

Policy contract number

13020-0001-001

Policy instance

Insurance contract or identification number	13020-0001-001
Number of Individuals Covered	416
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,623
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $52,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,623
Insurance broker organization code?	3

ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )

Policy contract number

13020-0001-001

Policy instance

Insurance contract or identification number	13020-0001-001
Number of Individuals Covered	352
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,328
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $46,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,328
Insurance broker organization code?	3

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

Policy contract number

AI 960904

Policy instance

Insurance contract or identification number	AI 960904
Number of Individuals Covered	321
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $13,245
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $88,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,094
Insurance broker organization code?	3

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

Policy contract number

OK967035

Policy instance

Insurance contract or identification number	OK967035
Number of Individuals Covered	2181
Insurance policy start date	2020-08-01
Insurance policy end date	2021-08-01
Total amount of commissions paid to insurance broker	USD $22,500
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $37,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,500
Insurance broker organization code?	7

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

Policy contract number

CI 960871

Policy instance

Insurance contract or identification number	CI 960871
Number of Individuals Covered	632
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $17,704
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $118,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,033
Insurance broker organization code?	3

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

Policy contract number

VDT961408

Policy instance

Insurance contract or identification number	VDT961408
Number of Individuals Covered	575
Insurance policy start date	2020-08-01
Insurance policy end date	2021-08-01
Total amount of commissions paid to insurance broker	USD $22,500
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $285,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,500
Insurance broker organization code?	7

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

Policy contract number

LK963785

Policy instance

Insurance contract or identification number	LK963785
Number of Individuals Covered	626
Insurance policy start date	2020-08-01
Insurance policy end date	2021-08-01
Total amount of commissions paid to insurance broker	USD $22,500
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $484,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,500
Insurance broker organization code?	7

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

Policy contract number

FLX965455

Policy instance

Insurance contract or identification number	FLX965455
Number of Individuals Covered	2345
Insurance policy start date	2020-08-01
Insurance policy end date	2021-08-01
Total amount of commissions paid to insurance broker	USD $22,500
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $419,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,500
Insurance broker organization code?	7

ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )

Policy contract number

13020-0001-001

Policy instance

Insurance contract or identification number	13020-0001-001
Number of Individuals Covered	318
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,432
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $48,645
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

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

Policy contract number

AI 960904

Policy instance

Insurance contract or identification number	AI 960904
Number of Individuals Covered	318
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $10,574
Total amount of fees paid to insurance company	USD $2,351
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $70,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,574
Amount paid for insurance broker fees	2351
Additional information about fees paid to insurance broker	STANDARD COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

VDT961408

Policy instance

Insurance contract or identification number	VDT961408
Number of Individuals Covered	641
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $35,000
Total amount of fees paid to insurance company	USD $6,516
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $238,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,000
Amount paid for insurance broker fees	6516
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	7

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

Policy contract number

LK963785

Policy instance

Insurance contract or identification number	LK963785
Number of Individuals Covered	582
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $32,500
Total amount of fees paid to insurance company	USD $12,760
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $415,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,500
Amount paid for insurance broker fees	12760
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	7

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

Policy contract number

CI 960871

Policy instance

Insurance contract or identification number	CI 960871
Number of Individuals Covered	616
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,989
Total amount of fees paid to insurance company	USD $2,725
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $86,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,989
Amount paid for insurance broker fees	2725
Additional information about fees paid to insurance broker	STANDARD COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

OK967035

Policy instance

Insurance contract or identification number	OK967035
Number of Individuals Covered	2257
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $32,500
Total amount of fees paid to insurance company	USD $829
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $29,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,500
Amount paid for insurance broker fees	829
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	7

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

Policy contract number

FLX965455

Policy instance

Insurance contract or identification number	FLX965455
Number of Individuals Covered	2218
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $35,000
Total amount of fees paid to insurance company	USD $9,879
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $363,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,000
Amount paid for insurance broker fees	9879
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	7

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

Policy contract number

LK 963785

Policy instance

Insurance contract or identification number	LK 963785
Number of Individuals Covered	582
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $32,500
Total amount of fees paid to insurance company	USD $12,760
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $415,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,500
Amount paid for insurance broker fees	12760
Additional information about fees paid to insurance broker	SALES & SERVICES
Insurance broker organization code?	7

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

Policy contract number

161265

Policy instance

Insurance contract or identification number	161265
Number of Individuals Covered	4131
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $33,396
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,686
Insurance broker organization code?	3

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

Policy contract number

CI 960871

Policy instance

Insurance contract or identification number	CI 960871
Number of Individuals Covered	480
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $12,076
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $80,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,076
Insurance broker organization code?	3

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

Policy contract number

AI 960904

Policy instance

Insurance contract or identification number	AI 960904
Number of Individuals Covered	283
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $10,276
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $68,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,276
Insurance broker organization code?	3

ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )

Policy contract number

13020-0001-001

Policy instance

Insurance contract or identification number	13020-0001-001
Number of Individuals Covered	354
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,024
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $51,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,024
Insurance broker organization code?	3

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

Policy contract number

OK 967035

Policy instance

Insurance contract or identification number	OK 967035
Number of Individuals Covered	2257
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $32,500
Total amount of fees paid to insurance company	USD $829
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $29,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,500
Amount paid for insurance broker fees	829
Additional information about fees paid to insurance broker	SALES & SERVICES
Insurance broker organization code?	7

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

Policy contract number

FLX965455

Policy instance

Insurance contract or identification number	FLX965455
Number of Individuals Covered	2218
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $35,000
Total amount of fees paid to insurance company	USD $9,879
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $363,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,000
Amount paid for insurance broker fees	9879
Additional information about fees paid to insurance broker	SALES & SERVICES
Insurance broker organization code?	7

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

Policy contract number

VDT961408

Policy instance

Insurance contract or identification number	VDT961408
Number of Individuals Covered	641
Insurance policy start date	2019-08-01
Insurance policy end date	2020-08-01
Total amount of commissions paid to insurance broker	USD $35,000
Total amount of fees paid to insurance company	USD $6,516
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $238,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,000
Amount paid for insurance broker fees	6516
Additional information about fees paid to insurance broker	SALES & SERVICES
Insurance broker organization code?	7

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

Policy contract number

OK 967035

Policy instance

Insurance contract or identification number	OK 967035
Number of Individuals Covered	2188
Insurance policy start date	2018-08-01
Insurance policy end date	2019-08-01
Total amount of commissions paid to insurance broker	USD $35,379
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $35,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,000
Insurance broker organization code?	3

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

Policy contract number

VDT961408

Policy instance

Insurance contract or identification number	VDT961408
Number of Individuals Covered	623
Insurance policy start date	2018-08-01
Insurance policy end date	2019-08-01
Total amount of commissions paid to insurance broker	USD $37,759
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $272,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,759
Insurance broker organization code?	3

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

Policy contract number

12049684-0522

Policy instance

Insurance contract or identification number	12049684-0522
Number of Individuals Covered	1
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

LK 963785

Policy instance

Insurance contract or identification number	LK 963785
Number of Individuals Covered	556
Insurance policy start date	2018-08-01
Insurance policy end date	2019-08-01
Total amount of commissions paid to insurance broker	USD $40,078
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $645,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,000
Insurance broker organization code?	3

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

Policy contract number

12049684-0521

Policy instance

Insurance contract or identification number	12049684-0521
Number of Individuals Covered	940
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12049684-0520

Policy instance

Insurance contract or identification number	12049684-0520
Number of Individuals Covered	747
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

FLX965455

Policy instance

Insurance contract or identification number	FLX965455
Number of Individuals Covered	1924
Insurance policy start date	2018-08-01
Insurance policy end date	2019-08-01
Total amount of commissions paid to insurance broker	USD $38,745
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $384,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,000
Insurance broker organization code?	3

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

Policy contract number

000404002206

Policy instance

Insurance contract or identification number	000404002206
Number of Individuals Covered	229
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,465
Total amount of fees paid to insurance company	USD $2,051
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $49,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,324
Amount paid for insurance broker fees	2051
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )

Policy contract number

13020-0001-001

Policy instance

Insurance contract or identification number	13020-0001-001
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 $1,436
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $31,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,436
Insurance broker organization code?	3

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

Policy contract number

000405003117

Policy instance

Insurance contract or identification number	000405003117
Number of Individuals Covered	247
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,350
Total amount of fees paid to insurance company	USD $1,012
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $41,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,519
Amount paid for insurance broker fees	1012
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

12049684-0523

Policy instance

Insurance contract or identification number	12049684-0523
Number of Individuals Covered	16
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

LK 963785

Policy instance

Insurance contract or identification number	LK 963785
Number of Individuals Covered	628
Insurance policy start date	2016-08-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $41,315
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $252,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,315
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGNCY LLC

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

Policy contract number

7338

Policy instance

Insurance contract or identification number	7338
Number of Individuals Covered	1657
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
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

4365

Policy instance

Insurance contract or identification number	4365
Number of Individuals Covered	3469
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
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

12049684-0520

Policy instance

Insurance contract or identification number	12049684-0520
Number of Individuals Covered	695
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000404002206

Policy instance

Insurance contract or identification number	000404002206
Number of Individuals Covered	253
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9,743
Total amount of fees paid to insurance company	USD $1,210
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $64,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,244
Amount paid for insurance broker fees	1210
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	DAVID O. OBERKIRCHER

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

Policy contract number

VDT961408

Policy instance

Insurance contract or identification number	VDT961408
Number of Individuals Covered	605
Insurance policy start date	2016-08-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $42,616
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $193,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,616
Insurance broker organization code?	3
Insurance broker name	MARCH & MCLENNAN AGNCY LLC

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

Policy contract number

FLX965455

Policy instance

Insurance contract or identification number	FLX965455
Number of Individuals Covered	2125
Insurance policy start date	2016-08-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $42,621
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $285,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,621
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGNCY LLC

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

Policy contract number

OK 967035

Policy instance

Insurance contract or identification number	OK 967035
Number of Individuals Covered	2192
Insurance policy start date	2016-08-01
Insurance policy end date	2017-08-01
Total amount of commissions paid to insurance broker	USD $35,688
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $25,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,688
Insurance broker organization code?	3
Insurance broker name	MARCH & MCLENNAN AGNCY LLC

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

Policy contract number

12049684-0521

Policy instance

Insurance contract or identification number	12049684-0521
Number of Individuals Covered	883
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

000405003117

Policy instance

Insurance contract or identification number	000405003117
Number of Individuals Covered	159
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,517
Total amount of fees paid to insurance company	USD $57
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $23,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,918
Amount paid for insurance broker fees	57
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	DAVID O. OBERKIRCHER

ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )

Policy contract number

13020-0001-001

Policy instance

Insurance contract or identification number	13020-0001-001
Number of Individuals Covered	266
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,762
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $35,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,762
Insurance broker organization code?	3
Insurance broker name	TRION, A MARCH & MCLENNAN AGENCY

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

Policy contract number

4365

Policy instance

Insurance contract or identification number	4365
Number of Individuals Covered	3214
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
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

FLX965455

Policy instance

Insurance contract or identification number	FLX965455
Number of Individuals Covered	1562
Insurance policy start date	2014-08-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $16,378
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $224,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,878
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

OK 967035

Policy instance

Insurance contract or identification number	OK 967035
Number of Individuals Covered	1740
Insurance policy start date	2014-08-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $27,887
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $22,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,387
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

7338

Policy instance

Insurance contract or identification number	7338
Number of Individuals Covered	1269
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
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

LK 963785

Policy instance

Insurance contract or identification number	LK 963785
Number of Individuals Covered	637
Insurance policy start date	2014-08-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $31,872
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $208,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,372
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

VDT961408

Policy instance

Insurance contract or identification number	VDT961408
Number of Individuals Covered	442
Insurance policy start date	2014-08-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $30,856
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,356
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

000404002206

Policy instance

Insurance contract or identification number	000404002206
Number of Individuals Covered	234
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,159
Total amount of fees paid to insurance company	USD $86
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $61,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,124
Insurance broker organization code?	3
Amount paid for insurance broker fees	86
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	MARCH & MCLENNAN AGNCY LLC

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

Policy contract number

000405003117

Policy instance

Insurance contract or identification number	000405003117
Number of Individuals Covered	113
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,989
Total amount of fees paid to insurance company	USD $44
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $26,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,748
Insurance broker organization code?	3
Amount paid for insurance broker fees	44
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	MARSH & MCLENNAN AGNCY LLC

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

Policy contract number

12049684-0520

Policy instance

Insurance contract or identification number	12049684-0520
Number of Individuals Covered	1246
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )

Policy contract number

13020-0001-001

Policy instance

Insurance contract or identification number	13020-0001-001
Number of Individuals Covered	200
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,608
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $32,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,608
Insurance broker organization code?	3
Insurance broker name	TRION, A MARCH & MCLENNAN AGENCY

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

Policy contract number

FLX965455

Policy instance

Insurance contract or identification number	FLX965455
Number of Individuals Covered	1526
Insurance policy start date	2013-08-01
Insurance policy end date	2014-08-01
Total amount of commissions paid to insurance broker	USD $25,000
Total amount of fees paid to insurance company	USD $3,941
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 $206,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,000
Amount paid for insurance broker fees	3941
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )

Policy contract number

13020-0001-001

Policy instance

Insurance contract or identification number	13020-0001-001
Number of Individuals Covered	186
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $739
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	LEGAL SERVICES
Welfare Benefit Premiums Paid to Carrier	USD $18,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $557
Insurance broker organization code?	3
Insurance broker name	MARSH A. TRION & MCLENNAN AGENCY

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

Policy contract number

000404002206

Policy instance

Insurance contract or identification number	000404002206
Number of Individuals Covered	332
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,470
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 $42,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,470
Insurance broker organization code?	3
Insurance broker name	DAVID OBERKIRCHER

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

Policy contract number

000405003117

Policy instance

Insurance contract or identification number	000405003117
Number of Individuals Covered	332
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,248
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	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $28,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,248
Insurance broker organization code?	3
Insurance broker name	DAIVD OBERKIRCHER

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

Policy contract number

12049684-0520

Policy instance

Insurance contract or identification number	12049684-0520
Number of Individuals Covered	1200
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4365

Policy instance

Insurance contract or identification number	4365
Number of Individuals Covered	3103
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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

7338

Policy instance

Insurance contract or identification number	7338
Number of Individuals Covered	1367
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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

OK 967035

Policy instance

Insurance contract or identification number	OK 967035
Number of Individuals Covered	1660
Insurance policy start date	2013-08-01
Insurance policy end date	2014-08-01
Total amount of commissions paid to insurance broker	USD $25,000
Total amount of fees paid to insurance company	USD $385
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 $19,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,000
Amount paid for insurance broker fees	385
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

LK 963785

Policy instance

Insurance contract or identification number	LK 963785
Number of Individuals Covered	628
Insurance policy start date	2013-08-01
Insurance policy end date	2014-08-01
Total amount of commissions paid to insurance broker	USD $25,000
Total amount of fees paid to insurance company	USD $4,548
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 $236,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,000
Amount paid for insurance broker fees	4548
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

VDT961408

Policy instance

Insurance contract or identification number	VDT961408
Number of Individuals Covered	426
Insurance policy start date	2013-08-01
Insurance policy end date	2014-08-01
Total amount of commissions paid to insurance broker	USD $25,000
Total amount of fees paid to insurance company	USD $4,241
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,000
Amount paid for insurance broker fees	4241
Additional information about fees paid to insurance broker	SALES AND SERVICE
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-011350-000

Policy instance

Insurance contract or identification number	16-011350-000
Number of Individuals Covered	1689
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $475,480
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

10079654 00000

Policy instance

Insurance contract or identification number	10079654 00000
Number of Individuals Covered	303
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,224
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 $40,786
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	1224
Additional information about fees paid to insurance broker	TPA FEE
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

10109680 00000

Policy instance

Insurance contract or identification number	10109680 00000
Number of Individuals Covered	1615
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,533
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $76,653
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	1533
Additional information about fees paid to insurance broker	TPA FEE
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

7338

Policy instance

Insurance contract or identification number	7338
Number of Individuals Covered	1467
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

400001000 09083

Policy instance

Insurance contract or identification number	400001000 09083
Number of Individuals Covered	1551
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,732
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 $86,582
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	1732
Additional information about fees paid to insurance broker	TPA FEE
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

4365

Policy instance

Insurance contract or identification number	4365
Number of Individuals Covered	2892
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
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
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

10149011 00000

Policy instance

Insurance contract or identification number	10149011 00000
Number of Individuals Covered	496
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $20,648
Total amount of fees paid to insurance company	USD $2,753
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $137,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,648
Insurance broker organization code?	3
Amount paid for insurance broker fees	2753
Additional information about fees paid to insurance broker	TPA FEE
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

400003002 02218

Policy instance

Insurance contract or identification number	400003002 02218
Number of Individuals Covered	314
Insurance policy start date	2013-01-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $2,312
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 $115,580
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	2312
Additional information about fees paid to insurance broker	TPA FEE
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

12049684-0520

Policy instance

Insurance contract or identification number	12049684-0520
Number of Individuals Covered	1134
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10149011 00000

Policy instance

Insurance contract or identification number	10149011 00000
Number of Individuals Covered	489
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $38,344
Total amount of fees paid to insurance company	USD $5,113
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $255,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,344
Insurance broker organization code?	3
Amount paid for insurance broker fees	5113
Additional information about fees paid to insurance broker	FEES
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

400001000 09083

Policy instance

Insurance contract or identification number	400001000 09083
Number of Individuals Covered	1391
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $9,694
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 $130,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7093
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

7338

Policy instance

Insurance contract or identification number	7338
Number of Individuals Covered	1654
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $344
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $344
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

400003002 02218

Policy instance

Insurance contract or identification number	400003002 02218
Number of Individuals Covered	275
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $14,817
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 $178,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	11250
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

12049684-0520

Policy instance

Insurance contract or identification number	12049684-0520
Number of Individuals Covered	1119
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-011350-000

Policy instance

Insurance contract or identification number	16-011350-000
Number of Individuals Covered	1724
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $526,390
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

4365

Policy instance

Insurance contract or identification number	4365
Number of Individuals Covered	2924
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,921
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,921
Insurance broker organization code?	3
Insurance broker name	PATRICK R. COLEMAN

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

Policy contract number

10109680 00000

Policy instance

Insurance contract or identification number	10109680 00000
Number of Individuals Covered	1598
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $11,591
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $126,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9053
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

10079654 00000

Policy instance

Insurance contract or identification number	10079654 00000
Number of Individuals Covered	288
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $7,469
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 $65,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5493
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT STRATEGIES INC

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

Policy contract number

400003002 02218

Policy instance

Insurance contract or identification number	400003002 02218
Number of Individuals Covered	290
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $40,619
Total amount of fees paid to insurance company	USD $4,165
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 $270,792
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

30022240

Policy instance

Insurance contract or identification number	30022240
Number of Individuals Covered	1069
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,965
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-011350-000

Policy instance

Insurance contract or identification number	16-011350-000
Number of Individuals Covered	1688
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $48,391
Total amount of fees paid to insurance company	USD $5,236
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 $483,914
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

10109680 00000

Policy instance

Insurance contract or identification number	10109680 00000
Number of Individuals Covered	1557
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,539
Total amount of fees paid to insurance company	USD $2,792
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $193,670
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

10079654 00000

Policy instance

Insurance contract or identification number	10079654 00000
Number of Individuals Covered	253
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,919
Total amount of fees paid to insurance company	USD $1,857
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 $122,077
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

400001000 09083

Policy instance

Insurance contract or identification number	400001000 09083
Number of Individuals Covered	1030
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $31,712
Total amount of fees paid to insurance company	USD $2,110
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 $158,557
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

7338

Policy instance

Insurance contract or identification number	7338
Number of Individuals Covered	1710
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $12,434
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

4365

Policy instance

Insurance contract or identification number	4365
Number of Individuals Covered	2750
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $24,696
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

7338

Policy instance

Insurance contract or identification number	7338
Number of Individuals Covered	2092
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,016
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,016
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

0008143093

Policy instance

Insurance contract or identification number	0008143093
Number of Individuals Covered	485
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $35,322
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,705
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

400003002 02218

Policy instance

Insurance contract or identification number	400003002 02218
Number of Individuals Covered	222
Insurance policy start date	2010-01-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $24,124
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $160,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,124
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

E3432705

Policy instance

Insurance contract or identification number	E3432705
Number of Individuals Covered	638
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $159,962
Total amount of fees paid to insurance company	USD $20,706
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $280,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $159,962
Amount paid for insurance broker fees	20706
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

00039

Policy instance

Insurance contract or identification number	00039
Number of Individuals Covered	76
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	MEDICARE SUPPLEMENT
Welfare Benefit Premiums Paid to Carrier	USD $93,376
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

12247313

Policy instance

Insurance contract or identification number	12247313
Number of Individuals Covered	1033
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,564
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 $167,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,564
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-011350-000

Policy instance

Insurance contract or identification number	16-011350-000
Number of Individuals Covered	1626
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $57,533
Total amount of fees paid to insurance company	USD $3,626
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 $575,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57,533
Amount paid for insurance broker fees	3626
Additional information about fees paid to insurance broker	GROUP VOLUME BONUS
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

4365

Policy instance

Insurance contract or identification number	4365
Number of Individuals Covered	2416
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $10,614
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,614
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

150755

Policy instance

Insurance contract or identification number	150755
Number of Individuals Covered	0
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $20
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

10109680 00000

Policy instance

Insurance contract or identification number	10109680 00000
Number of Individuals Covered	1296
Insurance policy start date	2010-01-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $2,531
Total amount of fees paid to insurance company	USD $3,890
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	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $111,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3890
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $2,531
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

10079654 00000

Policy instance

Insurance contract or identification number	10079654 00000
Number of Individuals Covered	203
Insurance policy start date	2010-01-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $4,268
Total amount of fees paid to insurance company	USD $1,917
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 $74,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,268
Insurance broker organization code?	3
Amount paid for insurance broker fees	1917
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	HYLANT GROUP INC.

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

Policy contract number

400001000 09083

Policy instance

Insurance contract or identification number	400001000 09083
Number of Individuals Covered	864
Insurance policy start date	2010-01-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $17,367
Total amount of fees paid to insurance company	USD $2,198
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 $78,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,798
Insurance broker organization code?	3
Amount paid for insurance broker fees	2198
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	TITAN BNFT COMMUNICATIONS LLC

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

Policy contract number

R0065318

Policy instance

Insurance contract or identification number	R0065318
Number of Individuals Covered	59
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,254
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	GROUP CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $4,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,173
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC.

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Company Name:	UNIVERSITY OF MICHIGAN HEALTH-WEST
Employer identification number (EIN):	380593405
NAIC Classification:	622000
NAIC Description:	Hospitals

Jurisdiction of Incorporation:	Michigan Secretary of State
Incorporation Date:	0000-00-00
Company Identification Number:	773062
Legal Registered Office Address:	5900 BYRON CENTER AVE SW WYOMING United States of America (USA) 49519