401k Plan data: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN plan

DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN
Plan identification number	516

DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

DETROIT DIESEL CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: DETROIT DIESEL CORPORATION

Employer identification number (EIN): 382772023

NAIC Classification: 333610

Additional information about DETROIT DIESEL CORPORATION

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 1987-12-18

Company Identification Number: 0007497306

Legal Registered Office Address: 13400 W OUTER DR STE 1

DETROIT
United States of America (USA)
48239

More information about DETROIT DIESEL CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
516 2022-01-01
516 2021-01-01
516 2020-01-01
516 2019-01-01
516 2018-01-01
516 2017-01-01 GREG SALWIN
516 2016-01-01 GREG SALWIN
516 2015-01-01 MARK PAGET
516 2014-01-01 LARRY ABBIATTI
516 2013-01-01 LARRY ABBIATTI
516 2012-01-01 LARRY ABBIATTI
516 2011-01-01 LARRY ABBIATTI

Plan Statistics for DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN

401k plan membership statisitcs for DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN

Measure Date Value
2022: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 1,834
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 1,868
Number of retired or separated participants receiving benefits 2022-01-01 24
Total of all active and inactive participants 2022-01-01 1,892
2021: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 1,887
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 1,834
Number of retired or separated participants receiving benefits 2021-01-01 24
Total of all active and inactive participants 2021-01-01 1,858
2020: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 1,885
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 1,887
Number of retired or separated participants receiving benefits 2020-01-01 3
Total of all active and inactive participants 2020-01-01 1,890
2019: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 1,701
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 1,879
Number of retired or separated participants receiving benefits 2019-01-01 6
Total of all active and inactive participants 2019-01-01 1,885
2018: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 2,297
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 1,699
Number of retired or separated participants receiving benefits 2018-01-01 2
Total of all active and inactive participants 2018-01-01 1,701
2017: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 2,454
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 2,187
Number of retired or separated participants receiving benefits 2017-01-01 110
Total of all active and inactive participants 2017-01-01 2,297
2016: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 2,443
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 2,432
Number of retired or separated participants receiving benefits 2016-01-01 22
Total of all active and inactive participants 2016-01-01 2,454
2015: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 2,432
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 2,432
Number of retired or separated participants receiving benefits 2015-01-01 11
Total of all active and inactive participants 2015-01-01 2,443
2014: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,162
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,162
Number of retired or separated participants receiving benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 1,164
2013: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 2,015
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,566
Number of retired or separated participants receiving benefits 2013-01-01 4
Total of all active and inactive participants 2013-01-01 1,570
2012: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 1,005
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 2,006
Number of retired or separated participants receiving benefits 2012-01-01 9
Total of all active and inactive participants 2012-01-01 2,015
2011: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 10,312
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 10,312
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 10,312

Measure	Date	Value
2022: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,834
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,868
Number of retired or separated participants receiving benefits	2022-01-01	24
Total of all active and inactive participants	2022-01-01	1,892
2021: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	1,887
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	1,834
Number of retired or separated participants receiving benefits	2021-01-01	24
Total of all active and inactive participants	2021-01-01	1,858
2020: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	1,885
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	1,887
Number of retired or separated participants receiving benefits	2020-01-01	3
Total of all active and inactive participants	2020-01-01	1,890
2019: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	1,701
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	1,879
Number of retired or separated participants receiving benefits	2019-01-01	6
Total of all active and inactive participants	2019-01-01	1,885
2018: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	2,297
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	1,699
Number of retired or separated participants receiving benefits	2018-01-01	2
Total of all active and inactive participants	2018-01-01	1,701
2017: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	2,454
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	2,187
Number of retired or separated participants receiving benefits	2017-01-01	110
Total of all active and inactive participants	2017-01-01	2,297
2016: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	2,443
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	2,432
Number of retired or separated participants receiving benefits	2016-01-01	22
Total of all active and inactive participants	2016-01-01	2,454
2015: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	2,432
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	2,432
Number of retired or separated participants receiving benefits	2015-01-01	11
Total of all active and inactive participants	2015-01-01	2,443
2014: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,162
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,162
Number of retired or separated participants receiving benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	1,164
2013: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	2,015
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,566
Number of retired or separated participants receiving benefits	2013-01-01	4
Total of all active and inactive participants	2013-01-01	1,570
2012: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	1,005
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	2,006
Number of retired or separated participants receiving benefits	2012-01-01	9
Total of all active and inactive participants	2012-01-01	2,015
2011: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	10,312
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	10,312
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	10,312

Form 5500 Responses for DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN

2022: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
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: DETROIT DIESEL CORPORATION WELFARE 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: DETROIT DIESEL CORPORATION WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	237
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4437
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $95
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,482,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	95
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0160939

Policy instance

Insurance contract or identification number	0160939
Number of Individuals Covered	3620
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BTA - TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	474
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0159626

Policy instance

Insurance contract or identification number	0159626
Number of Individuals Covered	383
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $197,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1260

Policy instance

Insurance contract or identification number	1260
Number of Individuals Covered	481
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

8001

Policy instance

Insurance contract or identification number	8001
Number of Individuals Covered	237
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2999
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4273
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $55
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,337,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	55
Additional information about fees paid to insurance broker	NON MONETARY COMPENSATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	244
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	490
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1260

Policy instance

Insurance contract or identification number	1260
Number of Individuals Covered	493
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

8001

Policy instance

Insurance contract or identification number	8001
Number of Individuals Covered	235
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2959
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0160939

Policy instance

Insurance contract or identification number	0160939
Number of Individuals Covered	3620
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BTA - TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0159626

Policy instance

Insurance contract or identification number	0159626
Number of Individuals Covered	384
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $198,157
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

8001

Policy instance

Insurance contract or identification number	8001
Number of Individuals Covered	223
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4181
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 $53
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,271,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	53
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	239
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
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	484
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $362,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0159626

Policy instance

Insurance contract or identification number	0159626
Number of Individuals Covered	377
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $244,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1260

Policy instance

Insurance contract or identification number	1260
Number of Individuals Covered	487
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2984
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0160939

Policy instance

Insurance contract or identification number	0160939
Number of Individuals Covered	4181
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
Other welfare benefits provided	BTA - TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4385
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 $77
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,266,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	77
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	228
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	448
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $316,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0159626

Policy instance

Insurance contract or identification number	0159626
Number of Individuals Covered	296
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $161,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1260

Policy instance

Insurance contract or identification number	1260
Number of Individuals Covered	450
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

8001

Policy instance

Insurance contract or identification number	8001
Number of Individuals Covered	220
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2982
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0160939

Policy instance

Insurance contract or identification number	0160939
Number of Individuals Covered	4385
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
Other welfare benefits provided	BTA - TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )

Policy contract number

10008707

Policy instance

Insurance contract or identification number	10008707
Number of Individuals Covered	1823
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4237
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 $88
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,917,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	88
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	220
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	432
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $299,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0159626

Policy instance

Insurance contract or identification number	0159626
Number of Individuals Covered	282
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $141,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1260

Policy instance

Insurance contract or identification number	1260
Number of Individuals Covered	432
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

8001

Policy instance

Insurance contract or identification number	8001
Number of Individuals Covered	198
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2904
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

160939

Policy instance

Insurance contract or identification number	160939
Number of Individuals Covered	4331
Insurance policy start date	2018-05-01
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
Other welfare benefits provided	BTA - TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )

Policy contract number

10008707

Policy instance

Insurance contract or identification number	10008707
Number of Individuals Covered	1866
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0159626

Policy instance

Insurance contract or identification number	0159626
Number of Individuals Covered	249
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $135,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1260

Policy instance

Insurance contract or identification number	1260
Number of Individuals Covered	403
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

8001

Policy instance

Insurance contract or identification number	8001
Number of Individuals Covered	193
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2870
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

160939

Policy instance

Insurance contract or identification number	160939
Number of Individuals Covered	4831
Insurance policy start date	2016-05-01
Insurance policy end date	2017-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BTA - TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )

Policy contract number

10008707

Policy instance

Insurance contract or identification number	10008707
Number of Individuals Covered	1895
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	397
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $299,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	202
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4269
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $79
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,870,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	79
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AON RISK INSURANCE SERVICES WEST

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

Policy contract number

0159626

Policy instance

Insurance contract or identification number	0159626
Number of Individuals Covered	226
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
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $101,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	419
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $246,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	199
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4390
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 $4,577
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,207,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	4537
Additional information about fees paid to insurance broker	ADMIN FEES
Insurance broker organization code?	3
Insurance broker name	AON RISK INSURANCE SERVICES WEST

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	447
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $190,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AF9G

Policy instance

Insurance contract or identification number	GVTL0AF9G
Number of Individuals Covered	70
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
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $12,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUPR0AF9G

Policy instance

Insurance contract or identification number	GUPR0AF9G
Number of Individuals Covered	110
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
Other welfare benefits provided	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $33,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4280
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 $3,934
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 $1,410,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3919
Additional information about fees paid to insurance broker	ADMIN FEES NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AON RISK INSURANCE SERVICES WEST IN

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	198
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0AF9G

Policy instance

Insurance contract or identification number	GLUG0AF9G
Number of Individuals Covered	139
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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $37,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUG0AF7F

Policy instance

Insurance contract or identification number	GUG0AF7F
Number of Individuals Covered	979
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $400,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4249
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $17
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 $1,436,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	17
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	AON RISK INSURANCE SERVICES WEST IN

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

Policy contract number

8001

Policy instance

Insurance contract or identification number	8001
Number of Individuals Covered	186
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0AF9G

Policy instance

Insurance contract or identification number	GLUG0AF9G
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 $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
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $39,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUPR0AF9G

Policy instance

Insurance contract or identification number	GUPR0AF9G
Number of Individuals Covered	118
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $34,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AF9G

Policy instance

Insurance contract or identification number	GVTL0AF9G
Number of Individuals Covered	76
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $16,473
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	204
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2750
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1260

Policy instance

Insurance contract or identification number	1260
Number of Individuals Covered	452
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0AF7F

Policy instance

Insurance contract or identification number	GLTD0AF7F
Number of Individuals Covered	981
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $225,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	440
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $171,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ALTIUS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95407 )

Policy contract number

6702140000

Policy instance

Insurance contract or identification number	6702140000
Number of Individuals Covered	325
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,324,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	209
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,054
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,054
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

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

Policy contract number

GUG0AF7F

Policy instance

Insurance contract or identification number	GUG0AF7F
Number of Individuals Covered	1028
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $11,964
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 $409,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	11964
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

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

Policy contract number

GLTD0AF7F

Policy instance

Insurance contract or identification number	GLTD0AF7F
Number of Individuals Covered	1028
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $9,504
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 $231,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9504
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	445
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	4058
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,369,111
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

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2759
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AF9G

Policy instance

Insurance contract or identification number	GVTL0AF9G
Number of Individuals Covered	85
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $718
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	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $17,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	718
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

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

Policy contract number

GUPR0AF9G

Policy instance

Insurance contract or identification number	GUPR0AF9G
Number of Individuals Covered	118
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $557
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	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $35,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	557
Additional information about fees paid to insurance broker	OTHER COMPANSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

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

Policy contract number

GLUG0AF9G

Policy instance

Insurance contract or identification number	GLUG0AF9G
Number of Individuals Covered	161
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,589
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 $42,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1589
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES

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

Policy contract number

008001

Policy instance

Insurance contract or identification number	008001
Number of Individuals Covered	176
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ALTIUS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95407 )

Policy contract number

6702140000

Policy instance

Insurance contract or identification number	6702140000
Number of Individuals Covered	394
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,420,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )

Policy contract number

1260

Policy instance

Insurance contract or identification number	1260
Number of Individuals Covered	511
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH PLAN UPPER OHIO VALLEY (National Association of Insurance Commissioners NAIC id number: 95677 )

Policy contract number

1809154

Policy instance

Insurance contract or identification number	1809154
Number of Individuals Covered	4664
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
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 $474,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AF7F

Policy instance

Insurance contract or identification number	GVTL0AF7F
Number of Individuals Covered	733
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $29,555
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	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $332,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLTD0AF7F

Policy instance

Insurance contract or identification number	GLTD0AF7F
Number of Individuals Covered	1056
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $18,306
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 $189,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ALTIUS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95407 )

Policy contract number

6702140000

Policy instance

Insurance contract or identification number	6702140000
Number of Individuals Covered	796
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
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 $2,894,629
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

008001

Policy instance

Insurance contract or identification number	008001
Number of Individuals Covered	73
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
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 $70,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MCKINLEY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77216 )

Policy contract number

184

Policy instance

Insurance contract or identification number	184
Number of Individuals Covered	514
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $130,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0AF9G

Policy instance

Insurance contract or identification number	GLUG0AF9G
Number of Individuals Covered	166
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,085
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $42,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUPR0AF9G

Policy instance

Insurance contract or identification number	GUPR0AF9G
Number of Individuals Covered	1806
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,806
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	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $15,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GVTL0AF9G

Policy instance

Insurance contract or identification number	GVTL0AF9G
Number of Individuals Covered	2202
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,202
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	VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $18,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12005939

Policy instance

Insurance contract or identification number	12005939
Number of Individuals Covered	1179
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $22,218
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9086

Policy instance

Insurance contract or identification number	9086
Number of Individuals Covered	2701
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG0AF7F

Policy instance

Insurance contract or identification number	GLUG0AF7F
Number of Individuals Covered	1056
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $13,653
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $140,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUG0AF7F

Policy instance

Insurance contract or identification number	GUG0AF7F
Number of Individuals Covered	1065
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $41,155
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 $294,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0028790

Policy instance

Insurance contract or identification number	0028790
Number of Individuals Covered	2429
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
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,042,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	DETROIT DIESEL CORPORATION
Employer identification number (EIN):	382772023
NAIC Classification:	333610

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	1987-12-18
Company Identification Number:	0007497306
Legal Registered Office Address:	13400 W OUTER DR STE 1 DETROIT United States of America (USA) 48239