401k Plan data: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN plan

FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	501

FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

FORTIS CONSTRUCTION, INC. has sponsored the creation of one or more 401k plans.

Company Name: FORTIS CONSTRUCTION, INC.

Employer identification number (EIN): 412096320

NAIC Classification: 236200

Additional information about FORTIS CONSTRUCTION, INC.

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division

Incorporation Date: 2003-05-20

Company Identification Number: 15045495

Legal Registered Office Address: 698 12TH ST SE SUITE 200

SALEM
United States of America (USA)
97301

More information about FORTIS CONSTRUCTION, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 CHRISTINA YORK 2024-06-26
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-09-01
501 2018-09-01
501 2017-09-01 MISTY BENDER
501 2016-09-01 MISTY BENDER
501 2015-09-01 MISTY BENDER
501 2014-09-01 MISTY BENDER

Plan Statistics for FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2023: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 306
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 392
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 392
Number of employers contributing to the scheme 2023-01-01 0
2022: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 349
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 306
Number of retired or separated participants receiving benefits 2022-01-01 3
Number of other retired or separated participants entitled to future benefits 2022-01-01 9
Total of all active and inactive participants 2022-01-01 318
2021: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 304
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 277
Number of retired or separated participants receiving benefits 2021-01-01 2
Number of other retired or separated participants entitled to future benefits 2021-01-01 3
Total of all active and inactive participants 2021-01-01 282
2020: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 315
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 317
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 2020-01-01 317
2019: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-09-01 305
Total number of active participants reported on line 7a of the Form 5500 2019-09-01 298
Number of retired or separated participants receiving benefits 2019-09-01 0
Number of other retired or separated participants entitled to future benefits 2019-09-01 0
Total of all active and inactive participants 2019-09-01 298
2018: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-09-01 198
Total number of active participants reported on line 7a of the Form 5500 2018-09-01 306
Number of retired or separated participants receiving benefits 2018-09-01 0
Number of other retired or separated participants entitled to future benefits 2018-09-01 0
Total of all active and inactive participants 2018-09-01 306
2017: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-09-01 167
Total number of active participants reported on line 7a of the Form 5500 2017-09-01 196
Number of retired or separated participants receiving benefits 2017-09-01 2
Number of other retired or separated participants entitled to future benefits 2017-09-01 0
Total of all active and inactive participants 2017-09-01 198
Total participants 2017-09-01 198
2016: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-09-01 147
Total number of active participants reported on line 7a of the Form 5500 2016-09-01 140
Number of retired or separated participants receiving benefits 2016-09-01 1
Number of other retired or separated participants entitled to future benefits 2016-09-01 0
Total of all active and inactive participants 2016-09-01 141
Total participants 2016-09-01 141
2015: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-09-01 109
Total number of active participants reported on line 7a of the Form 5500 2015-09-01 144
Number of retired or separated participants receiving benefits 2015-09-01 1
Number of other retired or separated participants entitled to future benefits 2015-09-01 1
Total of all active and inactive participants 2015-09-01 146
Total participants 2015-09-01 146
2014: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-09-01 89
Total number of active participants reported on line 7a of the Form 5500 2014-09-01 102
Number of retired or separated participants receiving benefits 2014-09-01 2
Number of other retired or separated participants entitled to future benefits 2014-09-01 3
Total of all active and inactive participants 2014-09-01 107
Total participants 2014-09-01 107

Measure	Date	Value
2023: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	306
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	392
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	392
Number of employers contributing to the scheme	2023-01-01	0
2022: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	349
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	306
Number of retired or separated participants receiving benefits	2022-01-01	3
Number of other retired or separated participants entitled to future benefits	2022-01-01	9
Total of all active and inactive participants	2022-01-01	318
2021: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	304
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	277
Number of retired or separated participants receiving benefits	2021-01-01	2
Number of other retired or separated participants entitled to future benefits	2021-01-01	3
Total of all active and inactive participants	2021-01-01	282
2020: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	315
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	317
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	317
2019: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-09-01	305
Total number of active participants reported on line 7a of the Form 5500	2019-09-01	298
Number of retired or separated participants receiving benefits	2019-09-01	0
Number of other retired or separated participants entitled to future benefits	2019-09-01	0
Total of all active and inactive participants	2019-09-01	298
2018: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-09-01	198
Total number of active participants reported on line 7a of the Form 5500	2018-09-01	306
Number of retired or separated participants receiving benefits	2018-09-01	0
Number of other retired or separated participants entitled to future benefits	2018-09-01	0
Total of all active and inactive participants	2018-09-01	306
2017: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-09-01	167
Total number of active participants reported on line 7a of the Form 5500	2017-09-01	196
Number of retired or separated participants receiving benefits	2017-09-01	2
Number of other retired or separated participants entitled to future benefits	2017-09-01	0
Total of all active and inactive participants	2017-09-01	198
Total participants	2017-09-01	198
2016: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-09-01	147
Total number of active participants reported on line 7a of the Form 5500	2016-09-01	140
Number of retired or separated participants receiving benefits	2016-09-01	1
Number of other retired or separated participants entitled to future benefits	2016-09-01	0
Total of all active and inactive participants	2016-09-01	141
Total participants	2016-09-01	141
2015: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-09-01	109
Total number of active participants reported on line 7a of the Form 5500	2015-09-01	144
Number of retired or separated participants receiving benefits	2015-09-01	1
Number of other retired or separated participants entitled to future benefits	2015-09-01	1
Total of all active and inactive participants	2015-09-01	146
Total participants	2015-09-01	146
2014: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-09-01	89
Total number of active participants reported on line 7a of the Form 5500	2014-09-01	102
Number of retired or separated participants receiving benefits	2014-09-01	2
Number of other retired or separated participants entitled to future benefits	2014-09-01	3
Total of all active and inactive participants	2014-09-01	107
Total participants	2014-09-01	107

Form 5500 Responses for FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN

2023: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-09-01	Type of plan entity	Single employer plan
2019-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-09-01	Plan funding arrangement – Insurance	Yes
2019-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-09-01	Plan benefit arrangement – Insurance	Yes
2019-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-09-01	Type of plan entity	Single employer plan
2018-09-01	Plan funding arrangement – Insurance	Yes
2018-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-09-01	Plan benefit arrangement – Insurance	Yes
2018-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-09-01	Type of plan entity	Single employer plan
2017-09-01	Submission has been amended	No
2017-09-01	This submission is the final filing	No
2017-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-09-01	Plan is a collectively bargained plan	No
2017-09-01	Plan funding arrangement – Insurance	Yes
2017-09-01	Plan benefit arrangement – Insurance	Yes
2016: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-09-01	Type of plan entity	Single employer plan
2016-09-01	Submission has been amended	No
2016-09-01	This submission is the final filing	No
2016-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-09-01	Plan is a collectively bargained plan	No
2016-09-01	Plan funding arrangement – Insurance	Yes
2016-09-01	Plan benefit arrangement – Insurance	Yes
2015: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-09-01	Type of plan entity	Single employer plan
2015-09-01	Submission has been amended	No
2015-09-01	This submission is the final filing	No
2015-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-09-01	Plan is a collectively bargained plan	No
2015-09-01	Plan funding arrangement – Insurance	Yes
2015-09-01	Plan benefit arrangement – Insurance	Yes
2014: FORTIS CONSTRUCTION, INC. HEALTH AND WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-09-01	Type of plan entity	Single employer plan
2014-09-01	First time form 5500 has been submitted	Yes
2014-09-01	Submission has been amended	No
2014-09-01	This submission is the final filing	No
2014-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-09-01	Plan is a collectively bargained plan	No
2014-09-01	Plan funding arrangement – Insurance	Yes
2014-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

12601000

Policy instance

Insurance contract or identification number	12601000
Number of Individuals Covered	66
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,874
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $10,507
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

GLUG0AHL6

Policy instance

Insurance contract or identification number	GLUG0AHL6
Number of Individuals Covered	392
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $10,933
Total amount of fees paid to insurance company	USD $11,487
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CRITICAL ILLNESS,ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $198,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

OR192

Policy instance

Insurance contract or identification number	OR192
Number of Individuals Covered	112
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083070

Policy instance

Insurance contract or identification number	30083070
Number of Individuals Covered	324
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

167771

Policy instance

Insurance contract or identification number	167771
Number of Individuals Covered	13
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,625
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

914236

Policy instance

Insurance contract or identification number	914236
Number of Individuals Covered	12
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELAWARE AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62634 )

Policy contract number

4783

Policy instance

Insurance contract or identification number	4783
Number of Individuals Covered	3
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 11121 )

Policy contract number

EU422

Policy instance

Insurance contract or identification number	EU422
Number of Individuals Covered	14
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $700
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SUPPLEMENTAL BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $101,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083070

Policy instance

Insurance contract or identification number	30083070
Number of Individuals Covered	301
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542060

Policy instance

Insurance contract or identification number	00542060
Number of Individuals Covered	230
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $568
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	568
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

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

Policy contract number

GUDE0AHL6

Policy instance

Insurance contract or identification number	GUDE0AHL6
Number of Individuals Covered	46
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,745
Total amount of fees paid to insurance company	USD $312
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $11,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,745
Insurance broker organization code?	3
Amount paid for insurance broker fees	312
Additional information about fees paid to insurance broker	OTHER COMPENSATION

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0914236

Policy instance

Insurance contract or identification number	0914236
Number of Individuals Covered	12
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

OR192

Policy instance

Insurance contract or identification number	OR192
Number of Individuals Covered	94
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $4,660
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4660
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 11121 )

Policy contract number

EU422

Policy instance

Insurance contract or identification number	EU422
Number of Individuals Covered	9
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $450
Other welfare benefits provided	SUPPLEMENTAL BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $3,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $450
Insurance broker organization code?	3

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

Policy contract number

GUDH0AHL6

Policy instance

Insurance contract or identification number	GUDH0AHL6
Number of Individuals Covered	92
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,749
Total amount of fees paid to insurance company	USD $501
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,749
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Amount paid for insurance broker fees	501

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

Policy contract number

GVTL0AHL6

Policy instance

Insurance contract or identification number	GVTL0AHL6
Number of Individuals Covered	123
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,350
Total amount of fees paid to insurance company	USD $1,452
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $55,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,350
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Amount paid for insurance broker fees	1452

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

Policy contract number

GLUG0AHL6

Policy instance

Insurance contract or identification number	GLUG0AHL6
Number of Individuals Covered	370
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $983
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $34,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	983
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3

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

Policy contract number

GLTD0AHL6

Policy instance

Insurance contract or identification number	GLTD0AHL6
Number of Individuals Covered	370
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $2,065
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2065
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

167771

Policy instance

Insurance contract or identification number	167771
Number of Individuals Covered	6
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,423
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,388
Insurance broker organization code?	3

DELAWARE AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62634 )

Policy contract number

4783

Policy instance

Insurance contract or identification number	4783
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-015134-000

Policy instance

Insurance contract or identification number	16-015134-000
Number of Individuals Covered	307
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $14,715
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $331,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	14715
Additional information about fees paid to insurance broker	ADMINISTRATION BONUS
Insurance broker organization code?	3

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

OR192

Policy instance

Insurance contract or identification number	OR192
Number of Individuals Covered	80
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $4,067
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4067
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083070

Policy instance

Insurance contract or identification number	30083070
Number of Individuals Covered	278
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0914236

Policy instance

Insurance contract or identification number	0914236
Number of Individuals Covered	18
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,436
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

GUDE0AHL6

Policy instance

Insurance contract or identification number	GUDE0AHL6
Number of Individuals Covered	43
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,562
Total amount of fees paid to insurance company	USD $275
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $10,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,562
Amount paid for insurance broker fees	148
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542060

Policy instance

Insurance contract or identification number	00542060
Number of Individuals Covered	230
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $526
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	526
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 11121 )

Policy contract number

EU422

Policy instance

Insurance contract or identification number	EU422
Number of Individuals Covered	7
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $350
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $350
Insurance broker organization code?	3

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

Policy contract number

GUDH0AHL6

Policy instance

Insurance contract or identification number	GUDH0AHL6
Number of Individuals Covered	74
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,505
Total amount of fees paid to insurance company	USD $464
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,505
Amount paid for insurance broker fees	250
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0AHL6

Policy instance

Insurance contract or identification number	GVTL0AHL6
Number of Individuals Covered	122
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,261
Total amount of fees paid to insurance company	USD $3,090
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $48,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,261
Amount paid for insurance broker fees	1664
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0AHL6

Policy instance

Insurance contract or identification number	GLUG0AHL6
Number of Individuals Covered	335
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $1,783
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $32,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	960
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD0AHL6

Policy instance

Insurance contract or identification number	GLTD0AHL6
Number of Individuals Covered	335
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $4,309
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2320
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

167771

Policy instance

Insurance contract or identification number	167771
Number of Individuals Covered	6
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,831
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,819
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

16-015134-000

Policy instance

Insurance contract or identification number	16-015134-000
Number of Individuals Covered	270
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $1,416
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $288,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1416
Additional information about fees paid to insurance broker	ADMINISTRATION BONUS
Insurance broker organization code?	3

CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )

Policy contract number

FORTIS

Policy instance

Insurance contract or identification number	FORTIS
Number of Individuals Covered	317
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $11,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

OR192

Policy instance

Insurance contract or identification number	OR192
Number of Individuals Covered	66
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083070

Policy instance

Insurance contract or identification number	30083070
Number of Individuals Covered	257
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,420
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,420
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0914236

Policy instance

Insurance contract or identification number	0914236
Number of Individuals Covered	18
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,784
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,784
Insurance broker organization code?	3

ARMADACARE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MZ0934050H

Policy instance

Insurance contract or identification number	MZ0934050H
Number of Individuals Covered	7
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,050
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,050
Insurance broker organization code?	3

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

Policy contract number

GUDH0AHL6

Policy instance

Insurance contract or identification number	GUDH0AHL6
Number of Individuals Covered	53
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,418
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,418
Insurance broker organization code?	3

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

Policy contract number

GVTL0AHL6

Policy instance

Insurance contract or identification number	GVTL0AHL6
Number of Individuals Covered	135
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,132
Total amount of fees paid to insurance company	USD $4,248
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $47,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,132
Amount paid for insurance broker fees	2832
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3

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

Policy contract number

GLUG0AHL6

Policy instance

Insurance contract or identification number	GLUG0AHL6
Number of Individuals Covered	317
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $2,543
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $27,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1695
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3

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

Policy contract number

GLTD0AHL6

Policy instance

Insurance contract or identification number	GLTD0AHL6
Number of Individuals Covered	317
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $6,360
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4240
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

911869

Policy instance

Insurance contract or identification number	911869
Number of Individuals Covered	630
Insurance policy start date	2019-09-01
Insurance policy end date	2020-12-31
Welfare Benefit Premiums Paid to Carrier	USD $476,793
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

GUDE0AHL6

Policy instance

Insurance contract or identification number	GUDE0AHL6
Number of Individuals Covered	32
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $726
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $4,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $726
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542060

Policy instance

Insurance contract or identification number	00542060
Number of Individuals Covered	221
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ARMADACARE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MZ0934050H

Policy instance

Insurance contract or identification number	MZ0934050H
Number of Individuals Covered	7
Insurance policy start date	2019-09-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $350
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $350
Insurance broker organization code?	3

CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )

Policy contract number

FORTIS

Policy instance

Insurance contract or identification number	FORTIS
Number of Individuals Covered	150
Insurance policy start date	2019-09-01
Insurance policy end date	2019-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $1,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

FORTIS

Policy instance

Insurance contract or identification number	FORTIS
Number of Individuals Covered	51
Insurance policy start date	2019-09-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $875
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	875
Additional information about fees paid to insurance broker	RETENTION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083070

Policy instance

Insurance contract or identification number	30083070
Number of Individuals Covered	248
Insurance policy start date	2019-09-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,016
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,016
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0914236

Policy instance

Insurance contract or identification number	0914236
Number of Individuals Covered	24
Insurance policy start date	2019-09-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,173
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,138
Insurance broker organization code?	3

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

Policy contract number

G000ALH6

Policy instance

Insurance contract or identification number	G000ALH6
Number of Individuals Covered	49
Insurance policy start date	2019-09-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,120
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,120
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542060

Policy instance

Insurance contract or identification number	00542060
Number of Individuals Covered	216
Insurance policy start date	2019-09-01
Insurance policy end date	2019-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083070

Policy instance

Insurance contract or identification number	30083070
Number of Individuals Covered	242
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $600
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $600
Insurance broker organization code?	3

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

OR192

Policy instance

Insurance contract or identification number	OR192
Number of Individuals Covered	44
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $911
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 $546
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0914236

Policy instance

Insurance contract or identification number	0914236
Number of Individuals Covered	27
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $4,921
Total amount of fees paid to insurance company	USD $280
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $98,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,921
Amount paid for insurance broker fees	280
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

911869

Policy instance

Insurance contract or identification number	911869
Number of Individuals Covered	622
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

911869

Policy instance

Insurance contract or identification number	911869
Number of Individuals Covered	622
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Welfare Benefit Premiums Paid to Carrier	USD $35,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )

Policy contract number

FORTIS

Policy instance

Insurance contract or identification number	FORTIS
Number of Individuals Covered	150
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $4,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ARMADACARE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MZ0934050H

Policy instance

Insurance contract or identification number	MZ0934050H
Number of Individuals Covered	7
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $1,050
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $875
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00542060

Policy instance

Insurance contract or identification number	00542060
Number of Individuals Covered	214
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $12,056
Total amount of fees paid to insurance company	USD $1,108
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,836
Amount paid for insurance broker fees	1108
Additional information about fees paid to insurance broker	ADMIN
Insurance broker organization code?	3

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

Policy contract number

G000AHL6

Policy instance

Insurance contract or identification number	G000AHL6
Number of Individuals Covered	111
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,755
Total amount of fees paid to insurance company	USD $1,443
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $38,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,755
Amount paid for insurance broker fees	1443
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

G000AHL6

Policy instance

Insurance contract or identification number	G000AHL6
Number of Individuals Covered	268
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,602
Total amount of fees paid to insurance company	USD $943
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $24,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,602
Amount paid for insurance broker fees	943
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

G000AHL6

Policy instance

Insurance contract or identification number	G000AHL6
Number of Individuals Covered	268
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,115
Total amount of fees paid to insurance company	USD $2,366
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,115
Amount paid for insurance broker fees	2366
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD-0AHL6

Policy instance

Insurance contract or identification number	GLTD-0AHL6
Number of Individuals Covered	254
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $8,729
Total amount of fees paid to insurance company	USD $2,366
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $58,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

Z2605

Policy instance

Insurance contract or identification number	Z2605
Number of Individuals Covered	20
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $956
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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

GLUG-0AHL6

Policy instance

Insurance contract or identification number	GLUG-0AHL6
Number of Individuals Covered	254
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $3,451
Total amount of fees paid to insurance company	USD $943
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $23,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )

Policy contract number

N/A

Policy instance

Insurance contract or identification number	N/A
Number of Individuals Covered	150
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $3,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

KM05713583

Policy instance

Insurance contract or identification number	KM05713583
Number of Individuals Covered	0
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $722
Total amount of fees paid to insurance company	USD $72
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ARMADACARE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MZ0934050H

Policy instance

Insurance contract or identification number	MZ0934050H
Number of Individuals Covered	0
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $1,150
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $67,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

911869

Policy instance

Insurance contract or identification number	911869
Number of Individuals Covered	523
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $59,542
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $2,118,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30083070

Policy instance

Insurance contract or identification number	30083070
Number of Individuals Covered	196
Insurance policy start date	2018-05-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $940
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

KM05713583

Policy instance

Insurance contract or identification number	KM05713583
Number of Individuals Covered	523
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $6,265
Total amount of fees paid to insurance company	USD $2,091
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $129,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,265
Amount paid for insurance broker fees	2075
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LIBERTY BENEFITS GROUP

CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )

Policy contract number

N/A

Policy instance

Insurance contract or identification number	N/A
Number of Individuals Covered	59
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $2,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GLUG-0AHL6

Policy instance

Insurance contract or identification number	GLUG-0AHL6
Number of Individuals Covered	183
Insurance policy start date	2015-11-01
Insurance policy end date	2016-10-31
Total amount of commissions paid to insurance broker	USD $2,463
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $16,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,463
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

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

Policy contract number

GLTD-0AHL6

Policy instance

Insurance contract or identification number	GLTD-0AHL6
Number of Individuals Covered	183
Insurance policy start date	2015-11-01
Insurance policy end date	2016-10-31
Total amount of commissions paid to insurance broker	USD $6,019
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $40,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,019
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

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

Policy contract number

GUG-0AHL6

Policy instance

Insurance contract or identification number	GUG-0AHL6
Number of Individuals Covered	183
Insurance policy start date	2015-11-01
Insurance policy end date	2016-10-31
Total amount of commissions paid to insurance broker	USD $7,552
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $50,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,552
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 )

Policy contract number

100005090001

Policy instance

Insurance contract or identification number	100005090001
Number of Individuals Covered	143
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $33,844
Total amount of fees paid to insurance company	USD $1,750
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $1,258,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,844
Amount paid for insurance broker fees	1750
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

Z2605

Policy instance

Insurance contract or identification number	Z2605
Number of Individuals Covered	11
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $496
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $496
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

ARMADACARE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MZ0934050H

Policy instance

Insurance contract or identification number	MZ0934050H
Insurance policy start date	2015-10-01
Insurance policy end date	2016-09-30
Total amount of commissions paid to insurance broker	USD $216
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $44,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $216
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 )

Policy contract number

100005090001

Policy instance

Insurance contract or identification number	100005090001
Number of Individuals Covered	102
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $26,710
Total amount of fees paid to insurance company	USD $1,288
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $966,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,710
Amount paid for insurance broker fees	1288
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

ARMADACARE (National Association of Insurance Commissioners NAIC id number: 66281 )

Policy contract number

MZ0934050H

Policy instance

Insurance contract or identification number	MZ0934050H
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $234
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $45,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $234
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )

Policy contract number

N/A

Policy instance

Insurance contract or identification number	N/A
Number of Individuals Covered	59
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

12721

Policy instance

Insurance contract or identification number	12721
Number of Individuals Covered	7
Insurance policy start date	2014-09-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $156
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	156
Additional information about fees paid to insurance broker	FEES FOR ADMINISTRATIVE SERVICES
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

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

Policy contract number

KM05713583-G

Policy instance

Insurance contract or identification number	KM05713583-G
Number of Individuals Covered	349
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $4,692
Total amount of fees paid to insurance company	USD $234
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $87,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	41
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

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

Policy contract number

GLTD-0AHL6

Policy instance

Insurance contract or identification number	GLTD-0AHL6
Number of Individuals Covered	134
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $4,583
Total amount of fees paid to insurance company	USD $590
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,583
Amount paid for insurance broker fees	590
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

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

Policy contract number

GLUG-0AHL6

Policy instance

Insurance contract or identification number	GLUG-0AHL6
Number of Individuals Covered	134
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $1,850
Total amount of fees paid to insurance company	USD $253
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,850
Amount paid for insurance broker fees	253
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

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

Policy contract number

GUG-0AHL6

Policy instance

Insurance contract or identification number	GUG-0AHL6
Number of Individuals Covered	134
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $5,736
Total amount of fees paid to insurance company	USD $737
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $38,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,736
Amount paid for insurance broker fees	737
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )

Policy contract number

Z2605

Policy instance

Insurance contract or identification number	Z2605
Number of Individuals Covered	12
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $519
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $519
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	THE PARTNERS GROUP

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Company Name:	FORTIS CONSTRUCTION, INC.
Employer identification number (EIN):	412096320
NAIC Classification:	236200

Jurisdiction of Incorporation:	Oregon Secretary of State Corporations Division
Incorporation Date:	2003-05-20
Company Identification Number:	15045495
Legal Registered Office Address:	698 12TH ST SE SUITE 200 SALEM United States of America (USA) 97301

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-01-01	CHRISTINA YORK	2024-06-26
501	2022-01-01
501	2021-01-01
501	2020-01-01
501	2019-09-01
501	2018-09-01
501	2017-09-01	MISTY BENDER
501	2016-09-01	MISTY BENDER
501	2015-09-01	MISTY BENDER
501	2014-09-01	MISTY BENDER