401k Plan data: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN plan

COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 401k Plan overview

Plan Name	COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN
Plan identification number	501

COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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

401k Sponsoring company profile

COMMUNITY LIVING SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name: COMMUNITY LIVING SERVICES, INC.

Employer identification number (EIN): 382849658

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Additional information about COMMUNITY LIVING SERVICES, INC.

Jurisdiction of Incorporation: Virginia Secretary of State

Incorporation Date: 2005-07-26

Company Identification Number: 0642031

Legal Registered Office Address: 139 MICA RD

RIDGEWAY
United States of America (USA)
24148

More information about COMMUNITY LIVING SERVICES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 JAMES DEHEM
501 2017-01-01 JAMES DEHEM
501 2016-01-01 WILLIAM R. YORDY
501 2015-01-01 WILLIAM R. YORDY
501 2014-01-01 WILLIAM R. YORDY
501 2013-01-01 WILLIAM R. YORDY
501 2012-01-01 WILLIAM R. YORDY
501 2011-01-01 WILLIAM R. YORDY
501 2009-01-01 WILLIAM YORDY JAMES DEHEM 2010-07-30

Plan Statistics for COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN

401k plan membership statisitcs for COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN

Measure Date Value
2022: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 295
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 152
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 152
2021: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 310
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 295
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 295
2020: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 257
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 310
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 310
2019: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 384
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 257
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 257
2018: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 462
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 384
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 384
2017: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 445
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 462
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 462
2016: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 207
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 445
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 445
2015: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 207
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 207
2014: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 203
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 191
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 191
2013: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 207
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 203
Total of all active and inactive participants 2013-01-01 203
2012: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 193
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 207
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 207
2011: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 196
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 193
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 2011-01-01 193
2009: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 196
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 196
Total of all active and inactive participants 2009-01-01 196
Total participants 2009-01-01 196

Measure	Date	Value
2022: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	295
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	152
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	152
2021: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	310
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	295
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	295
2020: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	257
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	310
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	310
2019: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	384
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	257
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	257
2018: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	462
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	384
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	384
2017: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	445
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	462
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	462
2016: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	207
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	445
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	445
2015: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	207
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	207
2014: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	203
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	191
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	191
2013: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	207
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	203
Total of all active and inactive participants	2013-01-01	203
2012: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	193
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	207
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	207
2011: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	196
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	193
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	193
2009: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	196
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	196
Total of all active and inactive participants	2009-01-01	196
Total participants	2009-01-01	196

Form 5500 Responses for COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN

2022: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2019: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2018: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2017: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2016: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2015: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2014: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2013: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2012: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA 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 benefit arrangement – Insurance	Yes
2011: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: COMMUNITY LIVING SERVICES, INC. EMPLOYEE BENEFITS PLAN AND CAFETERIA PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	137
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,455
Total amount of fees paid to insurance company	USD $1,459
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $24,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,237
Insurance broker organization code?	3
Amount paid for insurance broker fees	1459

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

Policy contract number

159649

Policy instance

Insurance contract or identification number	159649
Number of Individuals Covered	246
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17,734
Total amount of fees paid to insurance company	USD $24,443
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 $12,045
Amount paid for insurance broker fees	15200
Insurance broker organization code?	3

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	256
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,839
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,295
Insurance broker organization code?	3

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

Policy contract number

294571 0800

Policy instance

Insurance contract or identification number	294571 0800
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $1,078
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $5,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,078
Insurance broker organization code?	3

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	136
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $6,878
Total amount of fees paid to insurance company	USD $4,106
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,266
Insurance broker organization code?	3
Amount paid for insurance broker fees	4106

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

Policy contract number

GLTD0143J

Policy instance

Insurance contract or identification number	GLTD0143J
Number of Individuals Covered	137
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,114
Total amount of fees paid to insurance company	USD $2,528
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $188
Amount paid for insurance broker fees	2528
Insurance broker organization code?	3

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	59
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,376
Total amount of fees paid to insurance company	USD $1,217
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,180
Insurance broker organization code?	3
Amount paid for insurance broker fees	1217

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	144
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $4,813
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $24,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,813
Insurance broker organization code?	3

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

Policy contract number

159649

Policy instance

Insurance contract or identification number	159649
Number of Individuals Covered	284
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $19,551
Total amount of fees paid to insurance company	USD $24,421
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 $19,551
Amount paid for insurance broker fees	20900
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	295
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,583
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,583
Insurance broker organization code?	3

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	144
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $2,431
Total amount of fees paid to insurance company	USD $1,400
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $24,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,431
Amount paid for insurance broker fees	1400
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	144
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $6,843
Total amount of fees paid to insurance company	USD $3,931
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,843
Amount paid for insurance broker fees	3931
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	63
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $2,029
Total amount of fees paid to insurance company	USD $1,210
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,029
Amount paid for insurance broker fees	1210
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	149
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $6,685
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $33,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,685
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLTD0143J

Policy instance

Insurance contract or identification number	GLTD0143J
Number of Individuals Covered	144
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $2,107
Total amount of fees paid to insurance company	USD $2,408
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,107
Amount paid for insurance broker fees	2408
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

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	138
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $18,913
Total amount of fees paid to insurance company	USD $22,800
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 $18,913
Amount paid for insurance broker fees	22800
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	154
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,133
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $35,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,133
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	148
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,333
Total amount of fees paid to insurance company	USD $2,489
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $23,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,333
Amount paid for insurance broker fees	2489
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	148
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,552
Total amount of fees paid to insurance company	USD $5,055
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,552
Amount paid for insurance broker fees	5055
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLTD0143J

Policy instance

Insurance contract or identification number	GLTD0143J
Number of Individuals Covered	148
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,007
Total amount of fees paid to insurance company	USD $2,417
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,007
Amount paid for insurance broker fees	2417
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	64
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,016
Total amount of fees paid to insurance company	USD $1,420
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,016
Amount paid for insurance broker fees	1420
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	310
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,970
Total amount of fees paid to insurance company	USD $245
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,970
Amount paid for insurance broker fees	245
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

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	115
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $17,292
Total amount of fees paid to insurance company	USD $22,800
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 $18,003
Amount paid for insurance broker fees	22800
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	257
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,553
Total amount of fees paid to insurance company	USD $320
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,553
Amount paid for insurance broker fees	320
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	119
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,148
Total amount of fees paid to insurance company	USD $3,145
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $41,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,148
Amount paid for insurance broker fees	3145
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	119
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $8,425
Total amount of fees paid to insurance company	USD $6,434
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,425
Amount paid for insurance broker fees	6434
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLDT0143J

Policy instance

Insurance contract or identification number	GLDT0143J
Number of Individuals Covered	119
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,014
Total amount of fees paid to insurance company	USD $3,073
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,014
Amount paid for insurance broker fees	3073
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	49
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,367
Total amount of fees paid to insurance company	USD $1,767
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,367
Amount paid for insurance broker fees	1767
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	124
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,724
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $38,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,724
Insurance broker organization code?	3

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

Policy contract number

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	164
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $25,128
Total amount of fees paid to insurance company	USD $25,411
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 $22,807
Amount paid for insurance broker fees	22800
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	384
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,906
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 $9,906
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	173
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,242
Total amount of fees paid to insurance company	USD $3,457
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $52,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,242
Amount paid for insurance broker fees	3457
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	172
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $10,723
Total amount of fees paid to insurance company	USD $7,081
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $107,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,723
Amount paid for insurance broker fees	7081
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GLDT0143J

Policy instance

Insurance contract or identification number	GLDT0143J
Number of Individuals Covered	173
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,561
Total amount of fees paid to insurance company	USD $3,378
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,561
Amount paid for insurance broker fees	3378
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	74
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,946
Total amount of fees paid to insurance company	USD $1,950
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,946
Amount paid for insurance broker fees	1950
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	170
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $10,370
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $47,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,370
Insurance broker organization code?	3

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	196
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,189
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $55,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,189
Insurance broker organization code?	3
Insurance broker name	JS CLARK AGENCY INC

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	88
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,250
Total amount of fees paid to insurance company	USD $1,891
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,250
Amount paid for insurance broker fees	1891
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GLTD0143J

Policy instance

Insurance contract or identification number	GLTD0143J
Number of Individuals Covered	210
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,815
Total amount of fees paid to insurance company	USD $3,154
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,815
Amount paid for insurance broker fees	3154
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	210
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11,802
Total amount of fees paid to insurance company	USD $6,604
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,802
Amount paid for insurance broker fees	6604
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	210
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,762
Total amount of fees paid to insurance company	USD $3,247
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $57,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,762
Amount paid for insurance broker fees	3247
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	462
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,935
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,935
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	194
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $21,595
Total amount of fees paid to insurance company	USD $26,931
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 $18,459
Amount paid for insurance broker fees	22800
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	204
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,051
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $60,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,051
Insurance broker organization code?	3
Insurance broker name	JS CLARK AGENCY INC

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	82
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,990
Total amount of fees paid to insurance company	USD $1,454
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,990
Amount paid for insurance broker fees	1454
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GLTD0143J

Policy instance

Insurance contract or identification number	GLTD0143J
Number of Individuals Covered	207
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,672
Total amount of fees paid to insurance company	USD $2,584
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,672
Amount paid for insurance broker fees	2584
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	206
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,328
Total amount of fees paid to insurance company	USD $4,999
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,328
Amount paid for insurance broker fees	4999
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	207
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,407
Total amount of fees paid to insurance company	USD $2,631
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $54,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,407
Amount paid for insurance broker fees	2631
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	454
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,875
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 $11,875
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	189
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $18,103
Total amount of fees paid to insurance company	USD $31,908
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 $13,865
Amount paid for insurance broker fees	22800
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY

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

Policy contract number

GLTD0143J

Policy instance

Insurance contract or identification number	GLTD0143J
Number of Individuals Covered	210
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,584
Total amount of fees paid to insurance company	USD $2,438
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,584
Amount paid for insurance broker fees	2438
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	209
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,999
Total amount of fees paid to insurance company	USD $4,249
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,999
Amount paid for insurance broker fees	4249
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	210
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,262
Total amount of fees paid to insurance company	USD $2,436
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $52,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,262
Amount paid for insurance broker fees	2436
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	191
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $21,041
Total amount of fees paid to insurance company	USD $35,171
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 $14,771
Amount paid for insurance broker fees	22800
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	210
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,431
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $62,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,431
Insurance broker organization code?	3
Insurance broker name	JS CLARK AGENCY INC

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	452
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,234
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,234
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	84
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,909
Total amount of fees paid to insurance company	USD $1,451
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,909
Amount paid for insurance broker fees	1451
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GLTD0143J

Policy instance

Insurance contract or identification number	GLTD0143J
Number of Individuals Covered	203
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,438
Total amount of fees paid to insurance company	USD $2,278
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,438
Amount paid for insurance broker fees	2278
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

GVTL0143J

Policy instance

Insurance contract or identification number	GVTL0143J
Number of Individuals Covered	83
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,902
Total amount of fees paid to insurance company	USD $1,350
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,902
Amount paid for insurance broker fees	1350
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	203
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $19,025
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $93,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,025
Insurance broker organization code?	3
Insurance broker name	JS CLARK AGENCY INC

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

Policy contract number

GLUG0143J

Policy instance

Insurance contract or identification number	GLUG0143J
Number of Individuals Covered	203
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,873
Total amount of fees paid to insurance company	USD $2,265
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $48,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,873
Amount paid for insurance broker fees	2265
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	450
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $11,463
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 $11,463
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	187
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $20,804
Total amount of fees paid to insurance company	USD $22,800
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 $14,980
Amount paid for insurance broker fees	22800
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY

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

Policy contract number

GUG0143J

Policy instance

Insurance contract or identification number	GUG0143J
Number of Individuals Covered	203
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,497
Total amount of fees paid to insurance company	USD $3,627
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,497
Amount paid for insurance broker fees	3627
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	458
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,804
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 $11,804
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	207
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,674
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $45,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,674
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	207
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,415
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,415
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	76
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $4,029
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,029
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

294571

Policy instance

Insurance contract or identification number	294571
Number of Individuals Covered	204
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,604
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $31,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,604
Insurance broker organization code?	3
Insurance broker name	JS CLARK AGENCY INC

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	206
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,659
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,659
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	182
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $40,625
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 $36,889
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	193
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,237
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	169
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $39,654
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

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	193
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,409
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $42,866
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

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	74
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,960
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,595
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

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	191
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $10,169
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,091
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

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	430
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11,504
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

48812

Policy instance

Insurance contract or identification number	48812
Number of Individuals Covered	174
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $37,864
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 $37,864
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3
Insurance broker name	PAUL KAHLER

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

Policy contract number

0007421

Policy instance

Insurance contract or identification number	0007421
Number of Individuals Covered	451
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $11,058
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 $11,058
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	196
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,165
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,165
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	196
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,038
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,038
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	77
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,842
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,842
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

G000143J

Policy instance

Insurance contract or identification number	G000143J
Number of Individuals Covered	196
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,719
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,719
Additional information about fees paid to insurance broker	NA
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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Company Name:	COMMUNITY LIVING SERVICES, INC.
Employer identification number (EIN):	382849658
NAIC Classification:	624100
NAIC Description:	Individual and Family Services

Jurisdiction of Incorporation:	Virginia Secretary of State
Incorporation Date:	2005-07-26
Company Identification Number:	0642031
Legal Registered Office Address:	139 MICA RD RIDGEWAY United States of America (USA) 24148