401k Plan data: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN plan

CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 401k Plan overview

Plan Name	CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN
Plan identification number	501

CONSUMERS CREDIT UNION INSURANCE 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

CREDIT UNIONS CHARTERED IN STATE OF MICH 1027 CONSUMERS CREDIT UNION has sponsored the creation of one or more 401k plans.

Company Name: CREDIT UNIONS CHARTERED IN STATE OF MICH 1027 CONSUMERS CREDIT UNION

Employer identification number (EIN): 381438667

NAIC Classification: 522130
NAIC Description: Credit Unions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 SHAWN D PREMER 2023-06-15
501 2021-01-01 SHAWN D PREMER 2022-06-28
501 2020-01-01 SHAWN D PREMER 2021-10-05
501 2019-01-01 SHAWN D PREMER 2020-10-07
501 2018-01-01 SHAWN D PREMER 2019-10-14
501 2017-01-01
501 2016-01-01
501 2016-01-01 KAITLIN RAGOTZY 2017-06-26
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 SHAWN D PREMER
501 2011-01-01 SHAWN D PREMER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	SHAWN D PREMER	2023-06-15
501	2021-01-01	SHAWN D PREMER	2022-06-28
501	2020-01-01	SHAWN D PREMER	2021-10-05
501	2019-01-01	SHAWN D PREMER	2020-10-07
501	2018-01-01	SHAWN D PREMER	2019-10-14
501	2017-01-01
501	2016-01-01
501	2016-01-01			KAITLIN RAGOTZY	2017-06-26
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	SHAWN D PREMER
501	2011-01-01	SHAWN D PREMER

Plan Statistics for CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN

401k plan membership statisitcs for CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN

Measure Date Value
2022: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 341
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 385
Number of retired or separated participants receiving benefits 2022-01-01 2
Total of all active and inactive participants 2022-01-01 387
2021: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 296
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 340
Number of retired or separated participants receiving benefits 2021-01-01 1
Total of all active and inactive participants 2021-01-01 341
2020: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 284
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 294
Number of other retired or separated participants entitled to future benefits 2020-01-01 2
Total of all active and inactive participants 2020-01-01 296
2019: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 214
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 284
Total of all active and inactive participants 2019-01-01 284
2018: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 208
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 214
Total of all active and inactive participants 2018-01-01 214
2017: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 208
Total of all active and inactive participants 2017-01-01 208
2016: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 174
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 191
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 191
2015: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 164
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 167
Number of retired or separated participants receiving benefits 2015-01-01 7
Total of all active and inactive participants 2015-01-01 174
2014: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 152
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 164
Total of all active and inactive participants 2014-01-01 164
Total participants 2014-01-01 164
2013: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 152
Total of all active and inactive participants 2013-01-01 152
2012: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 125
Total of all active and inactive participants 2012-01-01 125
2011: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 101
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 114
Total of all active and inactive participants 2011-01-01 114

Measure	Date	Value
2022: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	341
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	385
Number of retired or separated participants receiving benefits	2022-01-01	2
Total of all active and inactive participants	2022-01-01	387
2021: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	296
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	340
Number of retired or separated participants receiving benefits	2021-01-01	1
Total of all active and inactive participants	2021-01-01	341
2020: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	284
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	294
Number of other retired or separated participants entitled to future benefits	2020-01-01	2
Total of all active and inactive participants	2020-01-01	296
2019: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	214
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	284
Total of all active and inactive participants	2019-01-01	284
2018: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	208
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	214
Total of all active and inactive participants	2018-01-01	214
2017: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	208
Total of all active and inactive participants	2017-01-01	208
2016: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	174
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	191
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	191
2015: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	164
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	167
Number of retired or separated participants receiving benefits	2015-01-01	7
Total of all active and inactive participants	2015-01-01	174
2014: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	152
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	164
Total of all active and inactive participants	2014-01-01	164
Total participants	2014-01-01	164
2013: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	152
Total of all active and inactive participants	2013-01-01	152
2012: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	125
Total of all active and inactive participants	2012-01-01	125
2011: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	101
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	114
Total of all active and inactive participants	2011-01-01	114

Form 5500 Responses for CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN

2022: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: CONSUMERS CREDIT UNION INSURANCE 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: CONSUMERS CREDIT UNION INSURANCE 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: CONSUMERS CREDIT UNION INSURANCE 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: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	First time form 5500 has been submitted	Yes
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
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: CONSUMERS CREDIT UNION INSURANCE 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: CONSUMERS CREDIT UNION INSURANCE 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: CONSUMERS CREDIT UNION INSURANCE 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: CONSUMERS CREDIT UNION INSURANCE 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: CONSUMERS CREDIT UNION INSURANCE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
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

Insurance Providers Used on plan

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

Policy contract number

0001332

Policy instance

Insurance contract or identification number	0001332
Number of Individuals Covered	717
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,962
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,962
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	222
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,131
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D, VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $54,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,131
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010257919

Policy instance

Insurance contract or identification number	000010257919
Number of Individuals Covered	385
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,071
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,071
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010257920

Policy instance

Insurance contract or identification number	000010257920
Number of Individuals Covered	368
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,277
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $74,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,277
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

99450311001

Policy instance

Insurance contract or identification number	99450311001
Number of Individuals Covered	2
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $-2
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	COBRA
Welfare Benefit Premiums Paid to Carrier	USD $59
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
Insurance broker organization code?	3

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

Policy contract number

790718

Policy instance

Insurance contract or identification number	790718
Number of Individuals Covered	643
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $62,656
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,658,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,656
Insurance broker organization code?	3

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

Policy contract number

000010257918

Policy instance

Insurance contract or identification number	000010257918
Number of Individuals Covered	385
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,420
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,420
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

99254391001

Policy instance

Insurance contract or identification number	99254391001
Number of Individuals Covered	650
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,703
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,703
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

0001332

Policy instance

Insurance contract or identification number	0001332
Number of Individuals Covered	637
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,695
Total amount of fees paid to insurance company	USD $194
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,695
Amount paid for insurance broker fees	194
Additional information about fees paid to insurance broker	RETENTION BONUS
Insurance broker organization code?	3

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

Policy contract number

99254391001

Policy instance

Insurance contract or identification number	99254391001
Number of Individuals Covered	579
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,662
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,662
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010257919

Policy instance

Insurance contract or identification number	000010257919
Number of Individuals Covered	340
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,046
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,046
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

790718

Policy instance

Insurance contract or identification number	790718
Number of Individuals Covered	577
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $61,292
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,671,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,292
Amount paid for insurance broker fees	0
Insurance broker organization code?	1

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

Policy contract number

99450311001

Policy instance

Insurance contract or identification number	99450311001
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	COBRA
Welfare Benefit Premiums Paid to Carrier	USD $23
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
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010257920

Policy instance

Insurance contract or identification number	000010257920
Number of Individuals Covered	340
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,758
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $109,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,758
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	199
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,396
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D, VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $49,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,396
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

000010257918

Policy instance

Insurance contract or identification number	000010257918
Number of Individuals Covered	340
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,319
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,319
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

0001332

Policy instance

Insurance contract or identification number	0001332
Number of Individuals Covered	592
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,047
Total amount of fees paid to insurance company	USD $411
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 $6,047
Amount paid for insurance broker fees	411
Additional information about fees paid to insurance broker	NEW BUSINESS BONUS, RETENTION BONUS
Insurance broker organization code?	3

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

Policy contract number

99254391001

Policy instance

Insurance contract or identification number	99254391001
Number of Individuals Covered	544
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,630
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,630
Insurance broker organization code?	3

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

Policy contract number

000010257919

Policy instance

Insurance contract or identification number	000010257919
Number of Individuals Covered	293
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $926
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $926
Insurance broker organization code?	3

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

Policy contract number

790718

Policy instance

Insurance contract or identification number	790718
Number of Individuals Covered	519
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $54,520
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,974,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,520
Insurance broker organization code?	3

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

Policy contract number

99450311001

Policy instance

Insurance contract or identification number	99450311001
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19
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
Insurance broker organization code?	3

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

Policy contract number

000010257920

Policy instance

Insurance contract or identification number	000010257920
Number of Individuals Covered	293
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,513
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $90,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,513
Insurance broker organization code?	3

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

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	164
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,851
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $39,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,851
Insurance broker organization code?	3

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

Policy contract number

000010257918

Policy instance

Insurance contract or identification number	000010257918
Number of Individuals Covered	293
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,640
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,640
Insurance broker organization code?	3

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

Policy contract number

790718

Policy instance

Insurance contract or identification number	790718
Number of Individuals Covered	481
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $51,820
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,161,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,820
Insurance broker organization code?	3

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

Policy contract number

GUG0AJS3

Policy instance

Insurance contract or identification number	GUG0AJS3
Number of Individuals Covered	247
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,787
Total amount of fees paid to insurance company	USD $1,956
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $57,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,787
Amount paid for insurance broker fees	1956
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0001332

Policy instance

Insurance contract or identification number	0001332
Number of Individuals Covered	535
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,391
Total amount of fees paid to insurance company	USD $410
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 $6,391
Amount paid for insurance broker fees	410
Additional information about fees paid to insurance broker	NEW BUSINESS BONUS, RETENTION BONUS
Insurance broker organization code?	3

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

Policy contract number

99254391001

Policy instance

Insurance contract or identification number	99254391001
Number of Individuals Covered	500
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,828
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,169
Insurance broker organization code?	3

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

Policy contract number

GVTL0AJS3

Policy instance

Insurance contract or identification number	GVTL0AJS3
Number of Individuals Covered	124
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,458
Total amount of fees paid to insurance company	USD $1,298
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $29,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,458
Amount paid for insurance broker fees	1298
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

99450311001

Policy instance

Insurance contract or identification number	99450311001
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0AJS3

Policy instance

Insurance contract or identification number	GLTD0AJS3
Number of Individuals Covered	247
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,982
Total amount of fees paid to insurance company	USD $770
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,982
Amount paid for insurance broker fees	770
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0AJS3

Policy instance

Insurance contract or identification number	GLUG0AJS3
Number of Individuals Covered	247
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,983
Total amount of fees paid to insurance company	USD $398
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,983
Amount paid for insurance broker fees	398
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	6

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

Policy contract number

99254391001

Policy instance

Insurance contract or identification number	99254391001
Number of Individuals Covered	452
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,719
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,719
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GUG0AJS3

Policy instance

Insurance contract or identification number	GUG0AJS3
Number of Individuals Covered	251
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,235
Total amount of fees paid to insurance company	USD $1,806
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,235
Amount paid for insurance broker fees	1806
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

GLUG0AJS3

Policy instance

Insurance contract or identification number	GLUG0AJS3
Number of Individuals Covered	251
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,270
Total amount of fees paid to insurance company	USD $386
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,270
Amount paid for insurance broker fees	386
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	6

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

Policy contract number

790718

Policy instance

Insurance contract or identification number	790718
Number of Individuals Covered	472
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $366,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AJS3

Policy instance

Insurance contract or identification number	GVTL0AJS3
Number of Individuals Covered	85
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,537
Total amount of fees paid to insurance company	USD $1,109
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $23,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,537
Amount paid for insurance broker fees	1109
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

0001332

Policy instance

Insurance contract or identification number	0001332
Number of Individuals Covered	489
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,343
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,343
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLTD0AJS3

Policy instance

Insurance contract or identification number	GLTD0AJS3
Number of Individuals Covered	251
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,170
Total amount of fees paid to insurance company	USD $747
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,170
Amount paid for insurance broker fees	747
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

0001332

Policy instance

Insurance contract or identification number	0001332
Number of Individuals Covered	476
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,944
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,944
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

99254391001

Policy instance

Insurance contract or identification number	99254391001
Number of Individuals Covered	438
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,243
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,243
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

GUG0AJS3

Policy instance

Insurance contract or identification number	GUG0AJS3
Number of Individuals Covered	211
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,945
Total amount of fees paid to insurance company	USD $1,747
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,945
Amount paid for insurance broker fees	1747
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

GLUG0AJS3

Policy instance

Insurance contract or identification number	GLUG0AJS3
Number of Individuals Covered	211
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,270
Total amount of fees paid to insurance company	USD $373
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,270
Amount paid for insurance broker fees	373
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

GLTD0AJS3

Policy instance

Insurance contract or identification number	GLTD0AJS3
Number of Individuals Covered	211
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,170
Total amount of fees paid to insurance company	USD $723
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,170
Amount paid for insurance broker fees	723
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

790718

Policy instance

Insurance contract or identification number	790718
Number of Individuals Covered	460
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $282,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AJS3

Policy instance

Insurance contract or identification number	GVTL0AJS3
Number of Individuals Covered	88
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,330
Total amount of fees paid to insurance company	USD $1,058
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,330
Amount paid for insurance broker fees	1058
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

9925439

Policy instance

Insurance contract or identification number	9925439
Number of Individuals Covered	391
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,057
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,057
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

1332

Policy instance

Insurance contract or identification number	1332
Number of Individuals Covered	428
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $16,862
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,862
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

GUGAJS3

Policy instance

Insurance contract or identification number	GUGAJS3
Number of Individuals Covered	194
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,075
Total amount of fees paid to insurance company	USD $1,411
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,075
Amount paid for insurance broker fees	1411
Additional information about fees paid to insurance broker	ADMIN / BROKER FEES & INCENT / DEM MGMT / UTIL RVW
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

GLTDAJS3

Policy instance

Insurance contract or identification number	GLTDAJS3
Number of Individuals Covered	194
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,170
Total amount of fees paid to insurance company	USD $684
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,170
Amount paid for insurance broker fees	684
Additional information about fees paid to insurance broker	ADMIN / BROKER FEES & INCENT / DEM MGMT / UTIL RVW
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

405478-A

Policy instance

Insurance contract or identification number	405478-A
Number of Individuals Covered	178
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,676
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $267,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,676
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	NULTY INSURANCE AGENCY

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

Policy contract number

GLUGAJS3

Policy instance

Insurance contract or identification number	GLUGAJS3
Number of Individuals Covered	194
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,270
Total amount of fees paid to insurance company	USD $353
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,270
Amount paid for insurance broker fees	353
Additional information about fees paid to insurance broker	ADMIN / BROKER FEES & INCENT / DEM MGMT / UTIL RVW
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

718104

Policy instance

Insurance contract or identification number	718104
Number of Individuals Covered	362
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,152
Total amount of fees paid to insurance company	USD $57,779
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,417,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,420
Amount paid for insurance broker fees	42918
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT.
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

1332

Policy instance

Insurance contract or identification number	1332
Number of Individuals Covered	373
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,920
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,867
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	180
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,051
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,359
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	180
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,264
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $841
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	180
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,160
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 $14,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,437
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE NULTY AGENCY INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	162
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,623
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 $27,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,623
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

1332

Policy instance

Insurance contract or identification number	1332
Number of Individuals Covered	333
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $13,010
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 $13,010
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	163
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,156
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,156
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	162
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,015
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 $13,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,015
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

718104

Policy instance

Insurance contract or identification number	718104
Number of Individuals Covered	202
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,895
Total amount of fees paid to insurance company	USD $52,109
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,277,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,895
Amount paid for insurance broker fees	52109
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT.
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	135
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $985
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $985
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

1332

Policy instance

Insurance contract or identification number	1332
Number of Individuals Covered	304
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,633
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 $12,633
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	135
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,978
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 $23,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,978
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	135
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,722
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 $11,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,722
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

718104

Policy instance

Insurance contract or identification number	718104
Number of Individuals Covered	202
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $47,503
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,163,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,503
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARVIN OKUN AGENCY, INC.

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

Policy contract number

G000AJS3

Policy instance

Insurance contract or identification number	G000AJS3
Number of Individuals Covered	114
Insurance policy start date	2011-10-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,420
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

1332

Policy instance

Insurance contract or identification number	1332
Number of Individuals Covered	267
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $10,998
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

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

Policy contract number

013675

Policy instance

Insurance contract or identification number	013675
Number of Individuals Covered	109
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $8,615
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

013675

Policy instance

Insurance contract or identification number	013675
Number of Individuals Covered	109
Insurance policy start date	2011-07-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $2,261
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

718104

Policy instance

Insurance contract or identification number	718104
Number of Individuals Covered	202
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $32,863
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $799,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

CONSUMERS CREDIT UNION BASIC 401(K) PLAN AND TRUST [EIN = 420868865]

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Company Name:	CREDIT UNIONS CHARTERED IN STATE OF MICH 1027 CONSUMERS CREDIT UNION
Employer identification number (EIN):	381438667
NAIC Classification:	522130
NAIC Description:	Credit Unions