401k Plan data: MASTER MOLD LLC EMPLOYEE WELFARE PLAN plan

MASTER MOLD LLC EMPLOYEE WELFARE PLAN 401k Plan overview

Plan Name	MASTER MOLD LLC EMPLOYEE WELFARE PLAN
Plan identification number	501

MASTER MOLD LLC EMPLOYEE WELFARE 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

MASTER MOLD LLC has sponsored the creation of one or more 401k plans.

Company Name: MASTER MOLD LLC

Employer identification number (EIN): 391863073

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MASTER MOLD LLC EMPLOYEE WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01 JON BUTTS 2024-01-31
501 2021-07-01 JON BUTTS 2023-01-20
501 2020-07-01 JON BUTTS 2022-01-31
501 2019-07-01 JON BUTTS 2021-01-29
501 2018-07-01 TODD WEISBROD 2020-01-22
501 2017-07-01
501 2016-07-01
501 2015-07-01
501 2014-07-01 FAYE NORA
501 2013-07-01 FAYE NORA
501 2012-07-01 FAYE NORA
501 2011-07-01 FAYE NORA
501 2010-07-01 FAYE NORA
501 2009-07-01 FAYE NORA

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-07-01	JON BUTTS	2024-01-31
501	2021-07-01	JON BUTTS	2023-01-20
501	2020-07-01	JON BUTTS	2022-01-31
501	2019-07-01	JON BUTTS	2021-01-29
501	2018-07-01	TODD WEISBROD	2020-01-22
501	2017-07-01
501	2016-07-01
501	2015-07-01
501	2014-07-01	FAYE NORA
501	2013-07-01	FAYE NORA
501	2012-07-01	FAYE NORA
501	2011-07-01	FAYE NORA
501	2010-07-01	FAYE NORA
501	2009-07-01	FAYE NORA

Plan Statistics for MASTER MOLD LLC EMPLOYEE WELFARE PLAN

401k plan membership statisitcs for MASTER MOLD LLC EMPLOYEE WELFARE PLAN

Measure Date Value
2022: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 210
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 261
Total of all active and inactive participants 2022-07-01 261
2021: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 195
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 210
Total of all active and inactive participants 2021-07-01 210
2020: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 184
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 195
Total of all active and inactive participants 2020-07-01 195
2019: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 296
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 184
Total of all active and inactive participants 2019-07-01 184
2018: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 294
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 296
Total of all active and inactive participants 2018-07-01 296
2017: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 333
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 294
Total of all active and inactive participants 2017-07-01 294
2016: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 416
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 333
Total of all active and inactive participants 2016-07-01 333
2015: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 376
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 416
Total of all active and inactive participants 2015-07-01 416
2014: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 450
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 376
Total of all active and inactive participants 2014-07-01 376
2013: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 317
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 450
Total of all active and inactive participants 2013-07-01 450
2012: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 241
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 317
Total of all active and inactive participants 2012-07-01 317
Total participants 2012-07-01 0
2011: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-07-01 254
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 240
Number of retired or separated participants receiving benefits 2011-07-01 1
Total of all active and inactive participants 2011-07-01 241
Total participants 2011-07-01 241
2010: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 178
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 253
Number of retired or separated participants receiving benefits 2010-07-01 1
Total of all active and inactive participants 2010-07-01 254
2009: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 182
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 176
Number of retired or separated participants receiving benefits 2009-07-01 2
Total of all active and inactive participants 2009-07-01 178

Measure	Date	Value
2022: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	210
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	261
Total of all active and inactive participants	2022-07-01	261
2021: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	195
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	210
Total of all active and inactive participants	2021-07-01	210
2020: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	184
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	195
Total of all active and inactive participants	2020-07-01	195
2019: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	296
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	184
Total of all active and inactive participants	2019-07-01	184
2018: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	294
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	296
Total of all active and inactive participants	2018-07-01	296
2017: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	333
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	294
Total of all active and inactive participants	2017-07-01	294
2016: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	416
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	333
Total of all active and inactive participants	2016-07-01	333
2015: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	376
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	416
Total of all active and inactive participants	2015-07-01	416
2014: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	450
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	376
Total of all active and inactive participants	2014-07-01	376
2013: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	317
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	450
Total of all active and inactive participants	2013-07-01	450
2012: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	241
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	317
Total of all active and inactive participants	2012-07-01	317
Total participants	2012-07-01	0
2011: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	254
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	240
Number of retired or separated participants receiving benefits	2011-07-01	1
Total of all active and inactive participants	2011-07-01	241
Total participants	2011-07-01	241
2010: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	178
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	253
Number of retired or separated participants receiving benefits	2010-07-01	1
Total of all active and inactive participants	2010-07-01	254
2009: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	182
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	176
Number of retired or separated participants receiving benefits	2009-07-01	2
Total of all active and inactive participants	2009-07-01	178

Form 5500 Responses for MASTER MOLD LLC EMPLOYEE WELFARE PLAN

2022: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Submission has been amended	Yes
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: MASTER MOLD LLC EMPLOYEE WELFARE PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	This submission is the final filing	No
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	149
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $116,157
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $378,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	86660
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEE, UTILIZATION REVIEW, PPO FEES, TRANSPLANT INSURANC
Insurance broker organization code?	5

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	175
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $9,731
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,731
Insurance broker organization code?	3

SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )

Policy contract number

208700

Policy instance

Insurance contract or identification number	208700
Number of Individuals Covered	139
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $2,847
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,847
Insurance broker organization code?	3

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

Policy contract number

000010205623

Policy instance

Insurance contract or identification number	000010205623
Number of Individuals Covered	179
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $646
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $646
Insurance broker organization code?	3

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

Policy contract number

000010205624

Policy instance

Insurance contract or identification number	000010205624
Number of Individuals Covered	63
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $4,782
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,782
Insurance broker organization code?	3

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

Policy contract number

000400205625

Policy instance

Insurance contract or identification number	000400205625
Number of Individuals Covered	138
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $5,830
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,830
Insurance broker organization code?	3

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

Policy contract number

000010205626

Policy instance

Insurance contract or identification number	000010205626
Number of Individuals Covered	213
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $6,709
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,709
Insurance broker organization code?	3

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	165
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $9,963
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,963
Insurance broker organization code?	3

SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )

Policy contract number

208700

Policy instance

Insurance contract or identification number	208700
Number of Individuals Covered	130
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $3,662
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,662
Insurance broker organization code?	3

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

Policy contract number

000010205623

Policy instance

Insurance contract or identification number	000010205623
Number of Individuals Covered	156
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $586
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $586
Insurance broker organization code?	3

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

Policy contract number

000010205624

Policy instance

Insurance contract or identification number	000010205624
Number of Individuals Covered	62
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $4,735
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,735
Insurance broker organization code?	3

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

Policy contract number

000400205625

Policy instance

Insurance contract or identification number	000400205625
Number of Individuals Covered	132
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $5,877
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,877
Insurance broker organization code?	3

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

Policy contract number

000010205626

Policy instance

Insurance contract or identification number	000010205626
Number of Individuals Covered	189
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $6,447
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,447
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	149
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $20,417
Total amount of fees paid to insurance company	USD $117,696
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $388,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,417
Amount paid for insurance broker fees	87300
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEE, UTILIZATION REVIEW, PPO FEES, TRANSPLANT INSURNCE/
Insurance broker organization code?	5

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	162
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $9,381
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,381
Insurance broker organization code?	3

SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )

Policy contract number

208700

Policy instance

Insurance contract or identification number	208700
Number of Individuals Covered	140
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $3,069
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,069
Insurance broker organization code?	3

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

Policy contract number

000010205623

Policy instance

Insurance contract or identification number	000010205623
Number of Individuals Covered	170
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $582
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $582
Insurance broker organization code?	3

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

Policy contract number

000010205624

Policy instance

Insurance contract or identification number	000010205624
Number of Individuals Covered	70
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $4,696
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,696
Insurance broker organization code?	3

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

Policy contract number

000400205625

Policy instance

Insurance contract or identification number	000400205625
Number of Individuals Covered	155
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $5,509
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,509
Insurance broker organization code?	3

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

Policy contract number

000010205626

Policy instance

Insurance contract or identification number	000010205626
Number of Individuals Covered	214
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $7,090
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,090
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	156
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $121,121
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $355,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	91562
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEE, UTILIZATION REVIEW, PPO FEES, TRANSPLANT INSURANC
Insurance broker organization code?	5

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	155
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $12,850
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,850
Insurance broker organization code?	3

SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )

Policy contract number

208700

Policy instance

Insurance contract or identification number	208700
Number of Individuals Covered	135
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $3,672
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,672
Insurance broker organization code?	3

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

Policy contract number

000010205623

Policy instance

Insurance contract or identification number	000010205623
Number of Individuals Covered	176
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $708
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $708
Insurance broker organization code?	3

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

Policy contract number

000010205624

Policy instance

Insurance contract or identification number	000010205624
Number of Individuals Covered	68
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $5,787
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,787
Insurance broker organization code?	3

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

Policy contract number

000400205625

Policy instance

Insurance contract or identification number	000400205625
Number of Individuals Covered	148
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $7,333
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,333
Insurance broker organization code?	3

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

Policy contract number

000010205626

Policy instance

Insurance contract or identification number	000010205626
Number of Individuals Covered	218
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $8,945
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,945
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	137
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $17,694
Total amount of fees paid to insurance company	USD $107,309
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $336,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,694
Amount paid for insurance broker fees	75844
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEE, UTILIZATION REVIEW, PPO FEES, TRANSPLANT INSURANCE
Insurance broker organization code?	5

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	192
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $12,813
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,813
Insurance broker organization code?	3

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	0
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $-469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )

Policy contract number

208700

Policy instance

Insurance contract or identification number	208700
Number of Individuals Covered	154
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $3,395
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,395
Insurance broker organization code?	3

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

Policy contract number

000010205623

Policy instance

Insurance contract or identification number	000010205623
Number of Individuals Covered	225
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $720
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $720
Insurance broker organization code?	3

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

Policy contract number

000010205624

Policy instance

Insurance contract or identification number	000010205624
Number of Individuals Covered	86
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $5,500
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,500
Insurance broker organization code?	3

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

Policy contract number

000400205625

Policy instance

Insurance contract or identification number	000400205625
Number of Individuals Covered	193
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $7,300
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,300
Insurance broker organization code?	3

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

Policy contract number

000010205626

Policy instance

Insurance contract or identification number	000010205626
Number of Individuals Covered	287
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $9,004
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,004
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	172
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $16,025
Total amount of fees paid to insurance company	USD $114,886
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $304,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,025
Amount paid for insurance broker fees	80910
Additional information about fees paid to insurance broker	ADMINSTRATIVE FEE, UTILIZATION REVIEW, PPO FEES, TRANSPLANT INSURANCE
Insurance broker organization code?	5

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

Policy contract number

000010205626

Policy instance

Insurance contract or identification number	000010205626
Number of Individuals Covered	321
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $9,419
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,419
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

000400205625

Policy instance

Insurance contract or identification number	000400205625
Number of Individuals Covered	217
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $6,234
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,561
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,234
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

000010205624

Policy instance

Insurance contract or identification number	000010205624
Number of Individuals Covered	88
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $5,364
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,364
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

000010205623

Policy instance

Insurance contract or identification number	000010205623
Number of Individuals Covered	253
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $606
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $606
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )

Policy contract number

208700

Policy instance

Insurance contract or identification number	208700
Number of Individuals Covered	334
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,474
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,474
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	189
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $15,737
Total amount of fees paid to insurance company	USD $121,654
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $301,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,889
Amount paid for insurance broker fees	85129
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEE, UTILIZATION REVIEW, PPO FEES, TRANSPLANT INSURANC
Insurance broker organization code?	5
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	208
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $13,842
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,842
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

000400205625

Policy instance

Insurance contract or identification number	000400205625
Number of Individuals Covered	289
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $6,471
Total amount of fees paid to insurance company	USD $1,350
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,471
Amount paid for insurance broker fees	1350
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

000010205624

Policy instance

Insurance contract or identification number	000010205624
Number of Individuals Covered	117
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $5,618
Total amount of fees paid to insurance company	USD $1,153
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,618
Amount paid for insurance broker fees	1153
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

000010205623

Policy instance

Insurance contract or identification number	000010205623
Number of Individuals Covered	338
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $851
Total amount of fees paid to insurance company	USD $176
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $851
Amount paid for insurance broker fees	176
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )

Policy contract number

208700

Policy instance

Insurance contract or identification number	208700
Number of Individuals Covered	405
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $4,242
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,242
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	258
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $57,287
Total amount of fees paid to insurance company	USD $126,691
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $324,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,089
Amount paid for insurance broker fees	120293
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEE, UTILIZATION REVIEW, PPO FEES, TRANSPLANT INSURANC
Insurance broker organization code?	5
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	279
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $18,190
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,190
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

000010205626

Policy instance

Insurance contract or identification number	000010205626
Number of Individuals Covered	438
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $11,458
Total amount of fees paid to insurance company	USD $2,374
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,458
Amount paid for insurance broker fees	2374
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	375
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $2,448
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 $29,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,448
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES, INC.

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	250
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $50,606
Total amount of fees paid to insurance company	USD $126,252
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 $286,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,882
Amount paid for insurance broker fees	119942
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES, COBRA FEES, PREFERRED REVIEW, PPO FEES
Insurance broker organization code?	5
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	109
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $3,702
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 $34,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,702
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES, INC.

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	370
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $3,812
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 $71,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,812
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES, INC.

SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )

Policy contract number

208700

Policy instance

Insurance contract or identification number	208700
Number of Individuals Covered	434
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $4,206
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
Welfare Benefit Premiums Paid to Carrier	USD $42,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,206
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	308
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $18,463
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,463
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	241
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $46,828
Total amount of fees paid to insurance company	USD $105,396
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 $233,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,736
Amount paid for insurance broker fees	105396
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES, COBRA FEES, PREFERRED REVIEW, PPO FEES
Insurance broker organization code?	5
Insurance broker name	SECURITY INSURANCE SERVICES, INC.

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

129100 00000

Policy instance

Insurance contract or identification number	129100 00000
Number of Individuals Covered	251
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $15,995
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,995
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	113
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,780
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 $35,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,470
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES, INC.

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	333
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,757
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 $69,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,449
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES, INC.

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	338
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,427
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 $29,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,219
Insurance broker organization code?	3
Insurance broker name	ROBERTSON RYAN & ASSOCIATES, INC.

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

12910 00000

Policy instance

Insurance contract or identification number	12910 00000
Number of Individuals Covered	236
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $14,946
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 $14,946
Insurance broker organization code?	3
Insurance broker name	SECURITY INSURANCE SERVICES, INC

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	234
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $49,557
Total amount of fees paid to insurance company	USD $99,572
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $251,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,064
Insurance broker organization code?	3
Amount paid for insurance broker fees	99572
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES, COBRA FEES, PREFERRED REVIEW, PPO FEES
Insurance broker name	AUXIANT

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	277
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $2,387
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $187
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	119
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,648
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $295
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	272
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,345
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $273
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	247
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $3,227
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	119
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,843
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	251
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,186
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	212
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $43,502
Total amount of fees paid to insurance company	USD $90,506
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $218,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

12910 00000

Policy instance

Insurance contract or identification number	12910 00000
Number of Individuals Covered	219
Insurance policy start date	2011-07-01
Insurance policy end date	2012-07-30
Total amount of commissions paid to insurance broker	USD $14,692
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	250
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $2,900
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 $40,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

085175

Policy instance

Insurance contract or identification number	085175
Number of Individuals Covered	254
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $1,930
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 $21,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

M874

Policy instance

Insurance contract or identification number	M874
Number of Individuals Covered	209
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $34,965
Total amount of fees paid to insurance company	USD $68,165
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 $174,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

12910

Policy instance

Insurance contract or identification number	12910
Number of Individuals Covered	205
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $10,154
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

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Company Name:	MASTER MOLD LLC
Employer identification number (EIN):	391863073
NAIC Classification:	339900