401k Plan data: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN plan

JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 401k Plan overview

Plan Name	JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN
Plan identification number	501

JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

JEFFREY AUTOMOTIVE GROUP, INC. has sponsored the creation of one or more 401k plans.

Company Name: JEFFREY AUTOMOTIVE GROUP, INC.

Employer identification number (EIN): 382464888

NAIC Classification: 441110
NAIC Description: New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01 SUSAN M HAAS 2021-09-23
501 2019-01-01 SUSAN M HAAS 2020-10-13
501 2018-01-01 SUSAN M HAAS 2019-09-25
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 SUSAN M HAAS

Plan Statistics for JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN

401k plan membership statisitcs for JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN

Measure Date Value
2020: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 86
Total of all active and inactive participants 2020-01-01 86
2019: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 140
Total of all active and inactive participants 2019-01-01 140
2018: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 118
Total of all active and inactive participants 2018-01-01 118
2017: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 61
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 108
Total of all active and inactive participants 2017-01-01 108
2016: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 61
Total of all active and inactive participants 2016-01-01 61
2015: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 119
Number of retired or separated participants receiving benefits 2015-01-01 2
Total of all active and inactive participants 2015-01-01 121
2014: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 118
Total of all active and inactive participants 2014-01-01 118
2013: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 102
Total of all active and inactive participants 2013-01-01 102
2012: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 99
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 110
Total of all active and inactive participants 2012-01-01 110

Measure	Date	Value
2020: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	86
Total of all active and inactive participants	2020-01-01	86
2019: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	140
Total of all active and inactive participants	2019-01-01	140
2018: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	118
Total of all active and inactive participants	2018-01-01	118
2017: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	61
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	108
Total of all active and inactive participants	2017-01-01	108
2016: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	61
Total of all active and inactive participants	2016-01-01	61
2015: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	119
Number of retired or separated participants receiving benefits	2015-01-01	2
Total of all active and inactive participants	2015-01-01	121
2014: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	118
Total of all active and inactive participants	2014-01-01	118
2013: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	102
Total of all active and inactive participants	2013-01-01	102
2012: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	99
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	110
Total of all active and inactive participants	2012-01-01	110

Form 5500 Responses for JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN

2020: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE 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: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: JEFFREY AUTOMOTIVE GROUP, INC. INSURANCE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
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

Insurance Providers Used on plan

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F012753

Policy instance

Insurance contract or identification number	F012753
Number of Individuals Covered	55
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10086

Policy instance

Insurance contract or identification number	10086
Number of Individuals Covered	88
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,473
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,473
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

156986

Policy instance

Insurance contract or identification number	156986
Number of Individuals Covered	92
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,794
Total amount of fees paid to insurance company	USD $369
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,794
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BROKER BONUS

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

Policy contract number

165060

Policy instance

Insurance contract or identification number	165060
Number of Individuals Covered	83
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,588
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,196
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

156986

Policy instance

Insurance contract or identification number	156986
Number of Individuals Covered	69
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,041
Total amount of fees paid to insurance company	USD $19
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,041
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

404002305

Policy instance

Insurance contract or identification number	404002305
Number of Individuals Covered	7
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $381
Total amount of fees paid to insurance company	USD $75
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $381
Amount paid for insurance broker fees	75
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

0000167911

Policy instance

Insurance contract or identification number	0000167911
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $926
Total amount of fees paid to insurance company	USD $885
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $926
Amount paid for insurance broker fees	589
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

165060

Policy instance

Insurance contract or identification number	165060
Number of Individuals Covered	106
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,958
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,958
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

156986

Policy instance

Insurance contract or identification number	156986
Number of Individuals Covered	98
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $14,031
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,031
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

702285

Policy instance

Insurance contract or identification number	702285
Number of Individuals Covered	54
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,217
Total amount of fees paid to insurance company	USD $563
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,217
Amount paid for insurance broker fees	563
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

156986

Policy instance

Insurance contract or identification number	156986
Number of Individuals Covered	75
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,345
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,345
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F012753

Policy instance

Insurance contract or identification number	F012753
Number of Individuals Covered	140
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

404002305

Policy instance

Insurance contract or identification number	404002305
Number of Individuals Covered	16
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $795
Total amount of fees paid to insurance company	USD $19
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $5,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $795
Amount paid for insurance broker fees	19
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000403003013

Policy instance

Insurance contract or identification number	000403003013
Number of Individuals Covered	28
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $723
Total amount of fees paid to insurance company	USD $33
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $723
Amount paid for insurance broker fees	33
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10087647

Policy instance

Insurance contract or identification number	10087647
Number of Individuals Covered	96
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,528
Total amount of fees paid to insurance company	USD $254
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,528
Amount paid for insurance broker fees	254
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

404002305

Policy instance

Insurance contract or identification number	404002305
Number of Individuals Covered	18
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $802
Total amount of fees paid to insurance company	USD $61
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $802
Amount paid for insurance broker fees	61
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

702285

Policy instance

Insurance contract or identification number	702285
Number of Individuals Covered	60
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,316
Total amount of fees paid to insurance company	USD $1,326
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,316
Amount paid for insurance broker fees	1326
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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

Policy contract number

792194S001

Policy instance

Insurance contract or identification number	792194S001
Number of Individuals Covered	2
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $311
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $311
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )

Policy contract number

792194S001

Policy instance

Insurance contract or identification number	792194S001
Number of Individuals Covered	109
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $13,930
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $464,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,930
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

156986

Policy instance

Insurance contract or identification number	156986
Number of Individuals Covered	76
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $362
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $362
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F012753

Policy instance

Insurance contract or identification number	F012753
Number of Individuals Covered	103
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $96,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5478366

Policy instance

Insurance contract or identification number	5478366
Number of Individuals Covered	55
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,537
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,537
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

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

Policy contract number

61670

Policy instance

Insurance contract or identification number	61670
Number of Individuals Covered	83
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,329
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,329
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	ROBERT E VOGELEI

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000403003013

Policy instance

Insurance contract or identification number	000403003013
Number of Individuals Covered	31
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $591
Total amount of fees paid to insurance company	USD $64
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $591
Amount paid for insurance broker fees	64
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

404002305

Policy instance

Insurance contract or identification number	404002305
Number of Individuals Covered	15
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $913
Total amount of fees paid to insurance company	USD $157
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $913
Amount paid for insurance broker fees	157
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00156986

Policy instance

Insurance contract or identification number	00156986
Number of Individuals Covered	113
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $13,026
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,026
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	ROBERT E VOGELEI

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10087647

Policy instance

Insurance contract or identification number	10087647
Number of Individuals Covered	99
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,298
Total amount of fees paid to insurance company	USD $198
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,298
Amount paid for insurance broker fees	198
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

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

Policy contract number

61670

Policy instance

Insurance contract or identification number	61670
Number of Individuals Covered	3
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,030
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,030
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10087647

Policy instance

Insurance contract or identification number	10087647
Number of Individuals Covered	101
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,357
Total amount of fees paid to insurance company	USD $148
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $16,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,357
Amount paid for insurance broker fees	148
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00156986/G002

Policy instance

Insurance contract or identification number	00156986/G002
Number of Individuals Covered	119
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $476,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

404002305

Policy instance

Insurance contract or identification number	404002305
Number of Individuals Covered	16
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,071
Total amount of fees paid to insurance company	USD $146
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,071
Amount paid for insurance broker fees	146
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F012754

Policy instance

Insurance contract or identification number	F012754
Number of Individuals Covered	104
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,039
Total amount of fees paid to insurance company	USD $1,064
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,039
Amount paid for insurance broker fees	1064
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	RALPH C WILSON AGENCY INC

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00156986/C001

Policy instance

Insurance contract or identification number	00156986/C001
Number of Individuals Covered	2
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	COBRA
Welfare Benefit Premiums Paid to Carrier	USD $15,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00156986/C002

Policy instance

Insurance contract or identification number	00156986/C002
Number of Individuals Covered	1
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	COBRA
Welfare Benefit Premiums Paid to Carrier	USD $1,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000403003013

Policy instance

Insurance contract or identification number	000403003013
Number of Individuals Covered	42
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $939
Total amount of fees paid to insurance company	USD $38
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $939
Amount paid for insurance broker fees	38
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

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

Policy contract number

61670

Policy instance

Insurance contract or identification number	61670
Number of Individuals Covered	124
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,692
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,692
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10087647

Policy instance

Insurance contract or identification number	10087647
Number of Individuals Covered	102
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,587
Total amount of fees paid to insurance company	USD $604
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,969
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

00156986/0001

Policy instance

Insurance contract or identification number	00156986/0001
Number of Individuals Covered	117
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $448,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10168404

Policy instance

Insurance contract or identification number	10168404
Number of Individuals Covered	92
Insurance policy start date	2014-01-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $-319
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-2,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $507
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10168403

Policy instance

Insurance contract or identification number	10168403
Number of Individuals Covered	37
Insurance policy start date	2014-01-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $1,103
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $729
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

404002305

Policy instance

Insurance contract or identification number	404002305
Number of Individuals Covered	12
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $802
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $802
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

TAMA114

Policy instance

Insurance contract or identification number	TAMA114
Number of Individuals Covered	62
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,558
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,558
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE CONSULTING GROUP

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F012754

Policy instance

Insurance contract or identification number	F012754
Number of Individuals Covered	105
Insurance policy start date	2014-04-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,326
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,326
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	RALPH C WILSON AGENCY INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10087647

Policy instance

Insurance contract or identification number	10087647
Number of Individuals Covered	102
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,892
Total amount of fees paid to insurance company	USD $590
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $19,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,892
Amount paid for insurance broker fees	590
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

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

Policy contract number

61670

Policy instance

Insurance contract or identification number	61670
Number of Individuals Covered	65
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,248
Total amount of fees paid to insurance company	USD $1,520
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,248
Amount paid for insurance broker fees	1520
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10168404

Policy instance

Insurance contract or identification number	10168404
Number of Individuals Covered	102
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,580
Total amount of fees paid to insurance company	USD $804
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,580
Amount paid for insurance broker fees	804
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05996193

Policy instance

Insurance contract or identification number	TM05996193
Number of Individuals Covered	149
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,078
Total amount of fees paid to insurance company	USD $7
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,078
Amount paid for insurance broker fees	7
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10168403

Policy instance

Insurance contract or identification number	10168403
Number of Individuals Covered	37
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,432
Total amount of fees paid to insurance company	USD $705
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,432
Amount paid for insurance broker fees	705
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

404002305

Policy instance

Insurance contract or identification number	404002305
Number of Individuals Covered	16
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,208
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $5,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,208
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

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

Policy contract number

211656

Policy instance

Insurance contract or identification number	211656
Number of Individuals Covered	107
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,459
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,459
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

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

Policy contract number

61670

Policy instance

Insurance contract or identification number	61670
Number of Individuals Covered	70
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,476
Total amount of fees paid to insurance company	USD $355
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,476
Amount paid for insurance broker fees	355
Additional information about fees paid to insurance broker	OTHER COMMISSIONS PAID.
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

855350G

Policy instance

Insurance contract or identification number	855350G
Number of Individuals Covered	42
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,370
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,370
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

10087647

Policy instance

Insurance contract or identification number	10087647
Number of Individuals Covered	110
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,127
Total amount of fees paid to insurance company	USD $960
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,127
Amount paid for insurance broker fees	960
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	CAMBRIDGE FINANCIAL SERVICES, INC.

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Company Name:	JEFFREY AUTOMOTIVE GROUP, INC.
Employer identification number (EIN):	382464888
NAIC Classification:	441110
NAIC Description:	New Car Dealers

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2020-01-01	SUSAN M HAAS	2021-09-23
501	2019-01-01	SUSAN M HAAS	2020-10-13
501	2018-01-01	SUSAN M HAAS	2019-09-25
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	SUSAN M HAAS