401k Plan data: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN plan

H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN
Plan identification number	501

H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

H. W. KAUFMAN FINANCIAL GROUP,INC. has sponsored the creation of one or more 401k plans.

Company Name: H. W. KAUFMAN FINANCIAL GROUP,INC.

Employer identification number (EIN): 381903339

NAIC Classification: 524290

Form 5500 Filing Information

Submission information for form 5500 for 401k plan H.W. KAUFMAN FINANCIAL GROUP 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
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 DANIEL T. MULDOWNEY
501 2016-01-01 DANIEL T. MULDOWNEY
501 2015-01-01 DANIEL T. MULDOWNEY
501 2014-01-01 DANIEL T. MULDOWNEY
501 2013-01-01 DANIEL T. MULDOWNEY
501 2012-01-01 DANIEL T. MULDOWNEY
501 2011-01-01 ALAN JAY KAUFMAN
501 2009-01-01 ALAN J. KAUFMAN

Plan Statistics for H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 1,152
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 1,315
Number of retired or separated participants receiving benefits 2022-01-01 11
Number of other retired or separated participants entitled to future benefits 2022-01-01 30
Total of all active and inactive participants 2022-01-01 1,356
Total participants 2022-01-01 1,356
2021: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,173
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 1,152
Number of other retired or separated participants entitled to future benefits 2021-01-01 17
Total of all active and inactive participants 2021-01-01 1,169
Total participants 2021-01-01 1,169
2020: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 1,179
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,173
Number of retired or separated participants receiving benefits 2020-01-01 10
Number of other retired or separated participants entitled to future benefits 2020-01-01 85
Total of all active and inactive participants 2020-01-01 1,268
Total participants 2020-01-01 1,268
2019: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,247
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,179
Number of retired or separated participants receiving benefits 2019-01-01 8
Number of other retired or separated participants entitled to future benefits 2019-01-01 28
Total of all active and inactive participants 2019-01-01 1,215
Total participants 2019-01-01 1,215
2018: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 1,301
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,290
Number of retired or separated participants receiving benefits 2018-01-01 11
Number of other retired or separated participants entitled to future benefits 2018-01-01 30
Total of all active and inactive participants 2018-01-01 1,331
Total participants 2018-01-01 1,331
2017: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,647
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 1,266
Number of retired or separated participants receiving benefits 2017-01-01 11
Number of other retired or separated participants entitled to future benefits 2017-01-01 43
Total of all active and inactive participants 2017-01-01 1,320
Total participants 2017-01-01 1,320
2016: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,180
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,647
Number of retired or separated participants receiving benefits 2016-01-01 12
Number of other retired or separated participants entitled to future benefits 2016-01-01 56
Total of all active and inactive participants 2016-01-01 1,715
Total participants 2016-01-01 1,715
2015: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,152
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,180
Number of retired or separated participants receiving benefits 2015-01-01 20
Number of other retired or separated participants entitled to future benefits 2015-01-01 28
Total of all active and inactive participants 2015-01-01 1,228
Total participants 2015-01-01 0
2014: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,092
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,275
Number of retired or separated participants receiving benefits 2014-01-01 20
Number of other retired or separated participants entitled to future benefits 2014-01-01 31
Total of all active and inactive participants 2014-01-01 1,326
Total participants 2014-01-01 0
2013: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 947
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,061
Number of retired or separated participants receiving benefits 2013-01-01 8
Number of other retired or separated participants entitled to future benefits 2013-01-01 23
Total of all active and inactive participants 2013-01-01 1,092
Total participants 2013-01-01 0
2012: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 947
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 911
Number of retired or separated participants receiving benefits 2012-01-01 14
Number of other retired or separated participants entitled to future benefits 2012-01-01 22
Total of all active and inactive participants 2012-01-01 947
Total participants 2012-01-01 0
2011: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 897
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 928
Number of retired or separated participants receiving benefits 2011-01-01 12
Number of other retired or separated participants entitled to future benefits 2011-01-01 7
Total of all active and inactive participants 2011-01-01 947
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
2009: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 814
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 733
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 18
Total of all active and inactive participants 2009-01-01 751
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Number of participants with account balances 2009-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0
Number of employers contributing to the scheme 2009-01-01 0

Measure	Date	Value
2022: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,152
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,315
Number of retired or separated participants receiving benefits	2022-01-01	11
Number of other retired or separated participants entitled to future benefits	2022-01-01	30
Total of all active and inactive participants	2022-01-01	1,356
Total participants	2022-01-01	1,356
2021: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,173
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,152
Number of other retired or separated participants entitled to future benefits	2021-01-01	17
Total of all active and inactive participants	2021-01-01	1,169
Total participants	2021-01-01	1,169
2020: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,179
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,173
Number of retired or separated participants receiving benefits	2020-01-01	10
Number of other retired or separated participants entitled to future benefits	2020-01-01	85
Total of all active and inactive participants	2020-01-01	1,268
Total participants	2020-01-01	1,268
2019: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,247
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,179
Number of retired or separated participants receiving benefits	2019-01-01	8
Number of other retired or separated participants entitled to future benefits	2019-01-01	28
Total of all active and inactive participants	2019-01-01	1,215
Total participants	2019-01-01	1,215
2018: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,301
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,290
Number of retired or separated participants receiving benefits	2018-01-01	11
Number of other retired or separated participants entitled to future benefits	2018-01-01	30
Total of all active and inactive participants	2018-01-01	1,331
Total participants	2018-01-01	1,331
2017: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,647
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,266
Number of retired or separated participants receiving benefits	2017-01-01	11
Number of other retired or separated participants entitled to future benefits	2017-01-01	43
Total of all active and inactive participants	2017-01-01	1,320
Total participants	2017-01-01	1,320
2016: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,180
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,647
Number of retired or separated participants receiving benefits	2016-01-01	12
Number of other retired or separated participants entitled to future benefits	2016-01-01	56
Total of all active and inactive participants	2016-01-01	1,715
Total participants	2016-01-01	1,715
2015: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,152
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,180
Number of retired or separated participants receiving benefits	2015-01-01	20
Number of other retired or separated participants entitled to future benefits	2015-01-01	28
Total of all active and inactive participants	2015-01-01	1,228
Total participants	2015-01-01	0
2014: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,092
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,275
Number of retired or separated participants receiving benefits	2014-01-01	20
Number of other retired or separated participants entitled to future benefits	2014-01-01	31
Total of all active and inactive participants	2014-01-01	1,326
Total participants	2014-01-01	0
2013: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	947
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,061
Number of retired or separated participants receiving benefits	2013-01-01	8
Number of other retired or separated participants entitled to future benefits	2013-01-01	23
Total of all active and inactive participants	2013-01-01	1,092
Total participants	2013-01-01	0
2012: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	947
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	911
Number of retired or separated participants receiving benefits	2012-01-01	14
Number of other retired or separated participants entitled to future benefits	2012-01-01	22
Total of all active and inactive participants	2012-01-01	947
Total participants	2012-01-01	0
2011: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	897
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	928
Number of retired or separated participants receiving benefits	2011-01-01	12
Number of other retired or separated participants entitled to future benefits	2011-01-01	7
Total of all active and inactive participants	2011-01-01	947
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
2009: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	814
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	733
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	18
Total of all active and inactive participants	2009-01-01	751
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Number of participants with account balances	2009-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0
Number of employers contributing to the scheme	2009-01-01	0

Form 5500 Responses for H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN

2022: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP 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: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
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
2009: H.W. KAUFMAN FINANCIAL GROUP EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	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

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	2349
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $66,590
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC TERM LIFE, VOLUNTARY TERM LIF
Welfare Benefit Premiums Paid to Carrier	USD $391,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,590
Insurance broker organization code?	3

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

Policy contract number

06433A

Policy instance

Insurance contract or identification number	06433A
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,030
Other welfare benefits provided	MBA COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $10,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,030
Insurance broker organization code?	3

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

Policy contract number

566308 0001

Policy instance

Insurance contract or identification number	566308 0001
Number of Individuals Covered	14
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,734
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $18,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,367
Insurance broker organization code?	3

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	2346
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Welfare Benefit Premiums Paid to Carrier	USD $2,629,223
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

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	1958
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,478
Other welfare benefits provided	BASIC ACCIDENTAL & DEATH, VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $38,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,478
Insurance broker organization code?	3

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

Policy contract number

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1513
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $32,868
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $193,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,868
Insurance broker organization code?	3

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

Policy contract number

SHD961793

Policy instance

Insurance contract or identification number	SHD961793
Number of Individuals Covered	1248
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SHORT TERM DISABILITY ASO
Welfare Benefit Premiums Paid to Carrier	USD $19,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

3521

Policy instance

Insurance contract or identification number	3521
Number of Individuals Covered	718
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

566308 0800

Policy instance

Insurance contract or identification number	566308 0800
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $6,270
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $42,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,135

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

Policy contract number

566308 0999

Policy instance

Insurance contract or identification number	566308 0999
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $96
Other welfare benefits provided	GROUP, INDIVIDUAL LTC
Welfare Benefit Premiums Paid to Carrier	USD $1,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $96
Insurance broker organization code?	3

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	113
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $1,178
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNES, ISWL STN
Welfare Benefit Premiums Paid to Carrier	USD $24,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,021

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	18
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	5
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $222
Other welfare benefits provided	GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $2,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $222

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

Policy contract number

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	2214
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,809
Other welfare benefits provided	BASIC ACCIDENTAL & DEATH, VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $31,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,809
Insurance broker organization code?	3

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	2252
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Welfare Benefit Premiums Paid to Carrier	USD $2,345,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

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

Policy contract number

566308 0001

Policy instance

Insurance contract or identification number	566308 0001
Number of Individuals Covered	16
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $3,412
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $22,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,706

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	2214
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $58,589
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC TERM LIFE, VOLUNTARY TERM LIF
Welfare Benefit Premiums Paid to Carrier	USD $316,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,589
Insurance broker organization code?	3

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

Policy contract number

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1446
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $30,255
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $163,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,255
Insurance broker organization code?	3

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

Policy contract number

SHD961793

Policy instance

Insurance contract or identification number	SHD961793
Number of Individuals Covered	1274
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SHORT TERM DISABILITY ASO
Welfare Benefit Premiums Paid to Carrier	USD $17,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

06433A

Policy instance

Insurance contract or identification number	06433A
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,030
Other welfare benefits provided	MBA COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $10,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,030

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	5
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $222
Other welfare benefits provided	GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $2,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $222

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	14
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	117
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $1,251
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNES, ISWL STN
Welfare Benefit Premiums Paid to Carrier	USD $26,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,051

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

Policy contract number

566308 0999

Policy instance

Insurance contract or identification number	566308 0999
Number of Individuals Covered	1
Total amount of commissions paid to insurance broker	USD $96
Other welfare benefits provided	GROUP, INDIVIDUAL LTC
Welfare Benefit Premiums Paid to Carrier	USD $1,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $96

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

Policy contract number

566308 0800

Policy instance

Insurance contract or identification number	566308 0800
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $6,394
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $42,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,197

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	1173
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $36,287
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC LIFE; SUPP LIFE; DEPEND. LIFE
Welfare Benefit Premiums Paid to Carrier	USD $213,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,287
Insurance broker organization code?	3

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	128
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $1,660
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, ISWL
Welfare Benefit Premiums Paid to Carrier	USD $34,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,405
Insurance broker organization code?	3

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	20
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $8,028
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $52,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,062
Insurance broker organization code?	3

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	1173
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Welfare Benefit Premiums Paid to Carrier	USD $1,962,195
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

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	1173
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $3,674
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $21,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,674
Insurance broker organization code?	3

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

Policy contract number

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1173
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $19,146
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $112,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,146
Insurance broker organization code?	3

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	18
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	6
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $247
Other welfare benefits provided	GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $2,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $247

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	18
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,268
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

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1179
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $29,787
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $175,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,787
Insurance broker organization code?	3

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

Policy contract number

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	1179
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $5,606
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $32,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,606
Insurance broker organization code?	3

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	1179
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Welfare Benefit Premiums Paid to Carrier	USD $1,779,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	23
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $6,136
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $42,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,116
Insurance broker organization code?	3

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	144
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $1,789
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, ISWL
Welfare Benefit Premiums Paid to Carrier	USD $33,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,486
Insurance broker organization code?	3

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	1179
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $53,883
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC LIFE; SUPP LIFE; DEPEND. LIFE
Welfare Benefit Premiums Paid to Carrier	USD $317,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,883
Insurance broker organization code?	3

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	108
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,513
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,492,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,757
Insurance broker organization code?	3

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	6
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $256
Other welfare benefits provided	GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $2,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $256

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	27
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $6,383
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $43,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,239
Insurance broker organization code?	3

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	171
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $14,194
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,582,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,097
Insurance broker organization code?	3

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	1290
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $47,552
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC LIFE; SUPP LIFE; DEPEND. LIFE
Welfare Benefit Premiums Paid to Carrier	USD $283,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,552
Insurance broker organization code?	3

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	158
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $2,129
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, ISWL
Welfare Benefit Premiums Paid to Carrier	USD $42,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,628
Insurance broker organization code?	3

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	1290
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Welfare Benefit Premiums Paid to Carrier	USD $1,614,717
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

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	1290
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $4,877
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $28,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,877
Insurance broker organization code?	3

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

Policy contract number

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1290
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $28,981
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $172,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,981
Insurance broker organization code?	3

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	25
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	7
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $263
Other welfare benefits provided	GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $2,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $263

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	7
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $269
Other welfare benefits provided	GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $2,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $269
Insurance broker name	MICHAEL M. CICCHELLA

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	25
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	ALAN J. KAUFMAN

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	129
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,669
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $953,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,835
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES LLC

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	547
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $47,095
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC LIFE; SUPP LIFE; DEPEND. LIFE
Welfare Benefit Premiums Paid to Carrier	USD $314,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,095
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	172
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $2,351
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, ISWL
Welfare Benefit Premiums Paid to Carrier	USD $40,561
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,788
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER MORRIS

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	28
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $6,142
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $42,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,119
Insurance broker organization code?	3
Insurance broker name	ALAN J. KAUFMAN

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	1130
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Welfare Benefit Premiums Paid to Carrier	USD $1,364,458
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

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	1266
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $2,789
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $18,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,789
Insurance broker organization code?	3
Insurance broker name	CICHELLA & ASSOCIATES

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

Policy contract number

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1266
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $29,530
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $196,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,530
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	28
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	ALAN J. KAUFMAN

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

Policy contract number

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1180
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $21,958
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,958
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	1180
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $1,582
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $10,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,582
Insurance broker organization code?	3
Insurance broker name	CICHELLA & ASSOCIATES

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	2041
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Welfare Benefit Premiums Paid to Carrier	USD $1,136,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	32
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $7,306
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $51,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,871
Insurance broker organization code?	3
Insurance broker name	ALAN J. KAUFMAN

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	1180
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $26,766
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC LIFE; SUPP LIFE; DEPEND. LIFE
Welfare Benefit Premiums Paid to Carrier	USD $178,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,766
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
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 $12,619
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $857,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,310
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES LLC

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	211
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $2,913
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, ISWL
Welfare Benefit Premiums Paid to Carrier	USD $52,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,230
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER MORRIS

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	10
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $308
Other welfare benefits provided	GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $3,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $308
Insurance broker name	MICHAEL M. CICCHELLA

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	230
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $3,525
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, ISWL
Welfare Benefit Premiums Paid to Carrier	USD $52,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,715
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER MORRIS

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	165
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,528
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $765,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,264
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES LLC

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	1275
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $29,434
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC LIFE; SUPP LIFE; DEPEND. LIFE
Welfare Benefit Premiums Paid to Carrier	USD $196,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,434
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	11
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $3,846
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $25,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,923
Insurance broker organization code?	3
Insurance broker name	ALAN J. KAUFMAN

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	1867
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Welfare Benefit Premiums Paid to Carrier	USD $1,195,856
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

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	1275
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $1,727
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $11,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,727
Insurance broker organization code?	3
Insurance broker name	CICHELLA & ASSOCIATES

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

Policy contract number

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1275
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $23,764
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $158,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,764
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	1
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	ALAN J. KAUFMAN

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	12
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $397
Other welfare benefits provided	GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $3,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $397
Insurance broker name	MICHAEL M. CICCHELLA

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	245
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,622
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, ISWL
Welfare Benefit Premiums Paid to Carrier	USD $57,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,663
Insurance broker organization code?	3
Insurance broker name	CHRISTOPHER MORRIS

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

Policy contract number

126256

Policy instance

Insurance contract or identification number	126256
Number of Individuals Covered	7
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $10
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,854
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
Insurance broker organization code?	3
Insurance broker name	ALAN J. KAUFMAN

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	1686
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Welfare Benefit Premiums Paid to Carrier	USD $918,846
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

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	1092
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $17,515
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,515
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	1092
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,277
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $8,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,277
Insurance broker organization code?	3
Insurance broker name	CICHELLA & ASSOCIATES

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	145
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $17,628
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $603,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,814
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES LLC

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	1092
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $21,765
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC LIFE; SUPP LIFE; DEPEND. LIFE
Welfare Benefit Premiums Paid to Carrier	USD $145,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,765
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	42
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $6,530
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $42,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,333
Insurance broker organization code?	3
Insurance broker name	ALAN J. KAUFMAN

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

Policy contract number

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	911
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $23,798
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC LIFE; SUPP LIFE; DEPEND. LIFE
Welfare Benefit Premiums Paid to Carrier	USD $158,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,798
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	48
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $6,259
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP LTC, GROUP INDIV LTC
Welfare Benefit Premiums Paid to Carrier	USD $44,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,951
Insurance broker organization code?	3
Insurance broker name	MICHAEL M. CICCHELLA

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	1486
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Welfare Benefit Premiums Paid to Carrier	USD $944,751
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

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	911
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,377
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $9,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,377
Insurance broker organization code?	3
Insurance broker name	CICHELLA & ASSOCIATES

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

Policy contract number

0005366214

Policy instance

Insurance contract or identification number	0005366214
Number of Individuals Covered	264
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,430
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, ISWL
Welfare Benefit Premiums Paid to Carrier	USD $71,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $107
Insurance broker organization code?	3
Insurance broker name	STEVEN GRIFFIN

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	116
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,961
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $425,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,980
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES LLC

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

Policy contract number

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	911
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $18,345
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $122,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,345
Insurance broker organization code?	3
Insurance broker name	CICCHELLA & ASSOCIATES

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	21
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $666
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP CRITICAL INSURANCE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,651
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

OK965023

Policy instance

Insurance contract or identification number	OK965023
Number of Individuals Covered	928
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	123
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,980
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $429,774
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

LK962420

Policy instance

Insurance contract or identification number	LK962420
Number of Individuals Covered	928
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $13,886
Total amount of fees paid to insurance company	USD $2,423
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $92,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5366214

Policy instance

Insurance contract or identification number	5366214
Number of Individuals Covered	292
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,782
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, INDIVIDUAL CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $76,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	54
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,793
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $47,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0066431

Policy instance

Insurance contract or identification number	R0066431
Number of Individuals Covered	27
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $2,370
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP CRITICAL INSURANCE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

566308

Policy instance

Insurance contract or identification number	566308
Number of Individuals Covered	61
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $7,703
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP LTC, GROUP INDIVID LTC
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $53,725
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

FLX963373

Policy instance

Insurance contract or identification number	FLX963373
Number of Individuals Covered	887
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $33,557
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $223,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	1315
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
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $603,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA HEALTHCARE OF CA (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

3169584

Policy instance

Insurance contract or identification number	3169584
Number of Individuals Covered	66
Insurance policy start date	2010-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,569
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $284,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	H. W. KAUFMAN FINANCIAL GROUP,INC.
Employer identification number (EIN):	381903339
NAIC Classification:	524290