401k Plan data: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN plan

BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN
Plan identification number	502

BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

BARTELS LUTHERAN HOME has sponsored the creation of one or more 401k plans.

Company Name: BARTELS LUTHERAN HOME

Employer identification number (EIN): 420752685

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about BARTELS LUTHERAN HOME

Jurisdiction of Incorporation: Iowa Secretary of State Business Entities

Incorporation Date: 1950-10-31

Company Identification Number: 054771

Legal Registered Office Address: 1922 5TH AVENUE NW

WAVERLY
United States of America (USA)
50677

More information about BARTELS LUTHERAN HOME

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2022-01-01
502 2021-01-01
502 2020-01-01
502 2019-01-01
502 2018-01-01
502 2017-01-01 CINDY SCHAKE
502 2016-01-01 CINDY SCHAKE
502 2015-01-01 CINDY SCHAKE
502 2014-01-01 CINDY SCHAKE
502 2013-01-01 CINDY SCHAKE
502 2012-01-01 CINDY SCHAKE
502 2011-01-01 CINDY SCHAKE
502 2009-01-01 CINDY SCHAKE
502 2009-01-01 CINDY SCHAKE CINDY SCHAKE 2010-06-30
502 2009-01-01 CINDY SCHAKE
502 2009-01-01 CINDY SCHAKE

Plan Statistics for BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN

401k plan membership statisitcs for BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN

Measure Date Value
2022: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 117
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 117
2021: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 109
Total of all active and inactive participants 2021-01-01 109
2020: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 133
Total of all active and inactive participants 2020-01-01 133
2019: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 133
Total of all active and inactive participants 2019-01-01 133
2018: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 137
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 128
Total of all active and inactive participants 2018-01-01 128
2017: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 137
Total of all active and inactive participants 2017-01-01 137
2016: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 144
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 133
Total of all active and inactive participants 2016-01-01 133
2015: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 136
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 144
Total of all active and inactive participants 2015-01-01 144
2014: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 134
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 136
Total of all active and inactive participants 2014-01-01 136
2013: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 134
Total of all active and inactive participants 2013-01-01 134
2012: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 134
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 140
Total of all active and inactive participants 2012-01-01 140
2011: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 133
Number of retired or separated participants receiving benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 134
2009: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 146
Number of retired or separated participants receiving benefits 2009-01-01 1
Total of all active and inactive participants 2009-01-01 147

Measure	Date	Value
2022: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	117
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	117
2021: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	109
Total of all active and inactive participants	2021-01-01	109
2020: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	133
Total of all active and inactive participants	2020-01-01	133
2019: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	133
Total of all active and inactive participants	2019-01-01	133
2018: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	137
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	128
Total of all active and inactive participants	2018-01-01	128
2017: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	137
Total of all active and inactive participants	2017-01-01	137
2016: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	144
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	133
Total of all active and inactive participants	2016-01-01	133
2015: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	144
Total of all active and inactive participants	2015-01-01	144
2014: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	134
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	136
Total of all active and inactive participants	2014-01-01	136
2013: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	134
Total of all active and inactive participants	2013-01-01	134
2012: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	134
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	140
Total of all active and inactive participants	2012-01-01	140
2011: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	133
Number of retired or separated participants receiving benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	134
2009: BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	146
Number of retired or separated participants receiving benefits	2009-01-01	1
Total of all active and inactive participants	2009-01-01	147

Financial Data on BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN

Measure	Date	Value
2022 : BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN 2022 401k financial data
Total income from all sources	2022-12-31	$0
Total plan assets at end of year	2022-12-31	$0
Total plan assets at beginning of year	2022-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2022-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2022-12-31	$0

Form 5500 Responses for BARTELS LUTHERAN HOME WELFARE BENEFITS PLAN

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

Insurance Providers Used on plan

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

Policy contract number

GVTL0B6S9

Policy instance

Insurance contract or identification number	GVTL0B6S9
Number of Individuals Covered	28
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,831
Total amount of fees paid to insurance company	USD $1,018
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,831
Amount paid for insurance broker fees	705
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0911471

Policy instance

Insurance contract or identification number	0911471
Number of Individuals Covered	117
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $29,190
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $617,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	29190
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

607901514

Policy instance

Insurance contract or identification number	607901514
Number of Individuals Covered	94
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,345
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,228
Insurance broker organization code?	5

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35362

Policy instance

Insurance contract or identification number	35362
Number of Individuals Covered	66
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,992
Total amount of fees paid to insurance company	USD $649
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,992
Amount paid for insurance broker fees	649
Additional information about fees paid to insurance broker	SALES AND PERSISTENCY BONUS
Insurance broker organization code?	3

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

Policy contract number

GLTD0B6S9

Policy instance

Insurance contract or identification number	GLTD0B6S9
Number of Individuals Covered	19
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of fees paid to insurance company	USD $162
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	112
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

GLUG0B6S9

Policy instance

Insurance contract or identification number	GLUG0B6S9
Number of Individuals Covered	101
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $637
Total amount of fees paid to insurance company	USD $329
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $637
Amount paid for insurance broker fees	228
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GUG0BS9

Policy instance

Insurance contract or identification number	GUG0BS9
Number of Individuals Covered	115
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,721
Total amount of fees paid to insurance company	USD $2,112
Other welfare benefits provided	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $29,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,721
Amount paid for insurance broker fees	1462
Additional information about fees paid to insurance broker	AGENT OR BORKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0911471

Policy instance

Insurance contract or identification number	0911471
Number of Individuals Covered	75
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $34,195
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $726,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	34195
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

GLUG0B6S9

Policy instance

Insurance contract or identification number	GLUG0B6S9
Number of Individuals Covered	90
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $760
Total amount of fees paid to insurance company	USD $452
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $760
Insurance broker organization code?	3
Amount paid for insurance broker fees	339
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

GUG 0B6S9

Policy instance

Insurance contract or identification number	GUG 0B6S9
Number of Individuals Covered	108
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,197
Total amount of fees paid to insurance company	USD $2,732
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,197
Insurance broker organization code?	3
Amount paid for insurance broker fees	2049
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

GLTD0B6S9

Policy instance

Insurance contract or identification number	GLTD0B6S9
Number of Individuals Covered	18
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $209
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	157
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

GVTL0B6S9

Policy instance

Insurance contract or identification number	GVTL0B6S9
Number of Individuals Covered	35
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,351
Total amount of fees paid to insurance company	USD $1,140
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	TERM LIFE - VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $15,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,351
Insurance broker organization code?	3
Amount paid for insurance broker fees	855
Additional information about fees paid to insurance broker	OTHER COMPENSATION

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35362

Policy instance

Insurance contract or identification number	35362
Number of Individuals Covered	67
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,456
Total amount of fees paid to insurance company	USD $664
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,456
Amount paid for insurance broker fees	664
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

60790-1514

Policy instance

Insurance contract or identification number	60790-1514
Number of Individuals Covered	109
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,894
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,516
Insurance broker organization code?	3

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

Policy contract number

0911471

Policy instance

Insurance contract or identification number	0911471
Number of Individuals Covered	86
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $35,665
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $547,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	35665
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

GLUG0B6S9

Policy instance

Insurance contract or identification number	GLUG0B6S9
Number of Individuals Covered	0
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $838
Total amount of fees paid to insurance company	USD $209
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $838
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	209

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

Policy contract number

GUG 0B6S9

Policy instance

Insurance contract or identification number	GUG 0B6S9
Number of Individuals Covered	133
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,227
Total amount of fees paid to insurance company	USD $1,171
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,227
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	1171

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

Policy contract number

GLTD0B6S9

Policy instance

Insurance contract or identification number	GLTD0B6S9
Number of Individuals Covered	20
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $83
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	83
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

GVTL0B6S9

Policy instance

Insurance contract or identification number	GVTL0B6S9
Number of Individuals Covered	0
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,670
Total amount of fees paid to insurance company	USD $396
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	TERM LIFE - VOLUNTARY
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,670
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	396

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35362

Policy instance

Insurance contract or identification number	35362
Number of Individuals Covered	78
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,939
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,939
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

60790-1514

Policy instance

Insurance contract or identification number	60790-1514
Number of Individuals Covered	115
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,441
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,279
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35362

Policy instance

Insurance contract or identification number	35362
Number of Individuals Covered	78
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,939
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,939
Insurance broker organization code?	3

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

Policy contract number

GVTL0B6S9

Policy instance

Insurance contract or identification number	GVTL0B6S9
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,670
Total amount of fees paid to insurance company	USD $396
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	TERM LIFE - VOLUNTARY
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,670
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	396

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

Policy contract number

GLTD0B6S9

Policy instance

Insurance contract or identification number	GLTD0B6S9
Number of Individuals Covered	20
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $83
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	83
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

GUG 0B6S9

Policy instance

Insurance contract or identification number	GUG 0B6S9
Number of Individuals Covered	133
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,227
Total amount of fees paid to insurance company	USD $1,171
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,227
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	1171

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

Policy contract number

GLUG0B6S9

Policy instance

Insurance contract or identification number	GLUG0B6S9
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $838
Total amount of fees paid to insurance company	USD $209
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $838
Additional information about fees paid to insurance broker	AGENT OR BROKER OF RECORD
Insurance broker organization code?	3
Amount paid for insurance broker fees	209

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

Policy contract number

0911471

Policy instance

Insurance contract or identification number	0911471
Number of Individuals Covered	86
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $35,665
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $547,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	35665
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

60790-1514

Policy instance

Insurance contract or identification number	60790-1514
Number of Individuals Covered	115
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,441
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,279
Insurance broker organization code?	3

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

Policy contract number

0911471

Policy instance

Insurance contract or identification number	0911471
Number of Individuals Covered	87
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $33,880
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $645,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	33880
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

60790-1514

Policy instance

Insurance contract or identification number	60790-1514
Number of Individuals Covered	104
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,155
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,129
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35362

Policy instance

Insurance contract or identification number	35362
Number of Individuals Covered	73
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,454
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,454
Insurance broker organization code?	3

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

Policy contract number

GVTL0B6S9

Policy instance

Insurance contract or identification number	GVTL0B6S9
Number of Individuals Covered	51
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,568
Total amount of fees paid to insurance company	USD $256
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	TERM LIFE - VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $10,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,568
Amount paid for insurance broker fees	199
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

GLTD0B6S9

Policy instance

Insurance contract or identification number	GLTD0B6S9
Number of Individuals Covered	19
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $55
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	43
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

GUG 0B6S9

Policy instance

Insurance contract or identification number	GUG 0B6S9
Number of Individuals Covered	138
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,949
Total amount of fees paid to insurance company	USD $713
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,949
Amount paid for insurance broker fees	555
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

GLUG0B6S9

Policy instance

Insurance contract or identification number	GLUG0B6S9
Number of Individuals Covered	128
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $828
Total amount of fees paid to insurance company	USD $136
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $828
Amount paid for insurance broker fees	106
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35362

Policy instance

Insurance contract or identification number	35362
Number of Individuals Covered	69
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,220
Total amount of fees paid to insurance company	USD $536
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,220
Amount paid for insurance broker fees	536
Additional information about fees paid to insurance broker	SALES AND PERSISTENCY BONUS
Insurance broker organization code?	3
Insurance broker name	PEDERSEN DOWIE CLABBY & MCCAUSLAND

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

Policy contract number

G000B6S9

Policy instance

Insurance contract or identification number	G000B6S9
Number of Individuals Covered	56
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $962
Total amount of fees paid to insurance company	USD $712
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $962
Amount paid for insurance broker fees	655
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BENEFIT 1 INC DBA TRUENETWORK OF AD

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

Policy contract number

G000B6S9

Policy instance

Insurance contract or identification number	G000B6S9
Number of Individuals Covered	116
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $480
Total amount of fees paid to insurance company	USD $377
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $480
Amount paid for insurance broker fees	347
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BENEFIT 1 INC DBA TRUENETWORK OF AD

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

Policy contract number

G000B6S9

Policy instance

Insurance contract or identification number	G000B6S9
Number of Individuals Covered	1269
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,840
Total amount of fees paid to insurance company	USD $1,981
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,840
Amount paid for insurance broker fees	1823
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BENEFIT 1 INC DBA TRUENETWORK OF AD

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

Policy contract number

G000B6S9

Policy instance

Insurance contract or identification number	G000B6S9
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $154
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	142
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BENEFIT 1 INC DBA TRUENETWORK OF AD

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

Policy contract number

0911471

Policy instance

Insurance contract or identification number	0911471
Number of Individuals Covered	85
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $17,990
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $264,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	17990
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	PEDERSEN DOWIE CLABBY & MCCAUSLAND

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 181705

Policy instance

Insurance contract or identification number	VG 181705
Number of Individuals Covered	52
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $2,914
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	DEPEND LIFE VOLUNTARY DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $14,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,914
Insurance broker organization code?	3
Insurance broker name	PEDERSEN DOWIE CLABBY & MCCAUSLAND

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 119308

Policy instance

Insurance contract or identification number	LTD 119308
Number of Individuals Covered	19
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $408
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $408
Insurance broker organization code?	3
Insurance broker name	PEDERSEN DOWIE CLABBY & MCCAUSLAND

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 145598

Policy instance

Insurance contract or identification number	GL 145598
Number of Individuals Covered	116
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $640
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $640
Insurance broker organization code?	3
Insurance broker name	PEDERSEN DOWIE CLABBY & MCCAUSLAND

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 160316

Policy instance

Insurance contract or identification number	G 160316
Number of Individuals Covered	137
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $2,915
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,915
Insurance broker organization code?	3
Insurance broker name	PEDERSEN DOWIE CLABBY & MCCAUSLAND

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 181705

Policy instance

Insurance contract or identification number	VG 181705
Number of Individuals Covered	61
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,779
Total amount of fees paid to insurance company	USD $564
Other welfare benefits provided	DEPEND LIFE VOLUNTARY DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $18,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,779
Amount paid for insurance broker fees	564
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	THE ACCEL GROUP LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 119308

Policy instance

Insurance contract or identification number	LTD 119308
Number of Individuals Covered	17
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $355
Total amount of fees paid to insurance company	USD $70
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $355
Amount paid for insurance broker fees	70
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	THE ACCEL GROUP LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 145598

Policy instance

Insurance contract or identification number	GL 145598
Number of Individuals Covered	114
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $605
Total amount of fees paid to insurance company	USD $165
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $605
Amount paid for insurance broker fees	165
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	THE ACCEL GROUP LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 160316

Policy instance

Insurance contract or identification number	G 160316
Number of Individuals Covered	144
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,689
Total amount of fees paid to insurance company	USD $826
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,689
Amount paid for insurance broker fees	826
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	THE ACCEL GROUP LLC

COVENTRY HEALTH CARE OF IOWA (National Association of Insurance Commissioners NAIC id number: 95241 )

Policy contract number

7028530000

Policy instance

Insurance contract or identification number	7028530000
Number of Individuals Covered	101
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $28,832
Total amount of fees paid to insurance company	USD $7,490
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $574,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,968
Amount paid for insurance broker fees	7490
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LLC

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

7028530000

Policy instance

Insurance contract or identification number	7028530000
Number of Individuals Covered	0
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,176
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,176
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 160316

Policy instance

Insurance contract or identification number	G 160316
Number of Individuals Covered	136
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,567
Total amount of fees paid to insurance company	USD $835
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,567
Amount paid for insurance broker fees	835
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	THE ACCEL GROUP LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 145598

Policy instance

Insurance contract or identification number	GL 145598
Number of Individuals Covered	110
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $604
Total amount of fees paid to insurance company	USD $175
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $604
Amount paid for insurance broker fees	175
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	THE ACCEL GROUP LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 119308

Policy instance

Insurance contract or identification number	LTD 119308
Number of Individuals Covered	17
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $349
Total amount of fees paid to insurance company	USD $71
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $349
Amount paid for insurance broker fees	71
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	THE ACCEL GROUP LLC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 181705

Policy instance

Insurance contract or identification number	VG 181705
Number of Individuals Covered	67
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,757
Total amount of fees paid to insurance company	USD $594
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	DEPEND LIFE VOLUNTARY DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $18,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,757
Amount paid for insurance broker fees	594
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	THE ACCEL GROUP LLC

COVENTRY HEALTH CARE OF IOWA (National Association of Insurance Commissioners NAIC id number: 95241 )

Policy contract number

7028530000

Policy instance

Insurance contract or identification number	7028530000
Number of Individuals Covered	102
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $25,568
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $540,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,568
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LLC

COVENTRY HEALTH CARE OF IOWA (National Association of Insurance Commissioners NAIC id number: 95241 )

Policy contract number

7028530000

Policy instance

Insurance contract or identification number	7028530000
Number of Individuals Covered	109
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $15,424
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $284,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,424
Insurance broker name	FIRST INSURANCE SERVICES LC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 181705

Policy instance

Insurance contract or identification number	VG 181705
Number of Individuals Covered	71
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,902
Total amount of fees paid to insurance company	USD $594
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	DEPEND LIFE VOLUNTARY DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $19,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,902
Amount paid for insurance broker fees	594
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

7028530000

Policy instance

Insurance contract or identification number	7028530000
Number of Individuals Covered	2
Insurance policy start date	2013-07-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 119308

Policy instance

Insurance contract or identification number	LTD 119308
Number of Individuals Covered	19
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $350
Total amount of fees paid to insurance company	USD $71
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,334
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
Amount paid for insurance broker fees	71
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 145598

Policy instance

Insurance contract or identification number	GL 145598
Number of Individuals Covered	111
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $621
Total amount of fees paid to insurance company	USD $175
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $621
Amount paid for insurance broker fees	175
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 160316

Policy instance

Insurance contract or identification number	G 160316
Number of Individuals Covered	134
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,566
Total amount of fees paid to insurance company	USD $835
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,566
Amount paid for insurance broker fees	835
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )

Policy contract number

0QM1 052M

Policy instance

Insurance contract or identification number	0QM1 052M
Number of Individuals Covered	96
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $17,829
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $292,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,630
Insurance broker organization code?	3
Insurance broker name	MUTUAL MED INSURANCE SERVICES LLC

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

Policy contract number

509859

Policy instance

Insurance contract or identification number	509859
Number of Individuals Covered	79
Insurance policy start date	2013-01-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $2,292
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,100
Insurance broker organization code?	3
Insurance broker name	BOSIER AND ASSOCIATES INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 181705

Policy instance

Insurance contract or identification number	VG 181705
Number of Individuals Covered	70
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,556
Total amount of fees paid to insurance company	USD $590
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	DEPEND LIFE VOLUNTARY DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $17,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,556
Amount paid for insurance broker fees	590
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )

Policy contract number

0QM1 052M

Policy instance

Insurance contract or identification number	0QM1 052M
Number of Individuals Covered	100
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $30,241
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $572,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,212
Insurance broker organization code?	3
Insurance broker name	MUTUAL MED INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 119308

Policy instance

Insurance contract or identification number	LTD 119308
Number of Individuals Covered	20
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $394
Total amount of fees paid to insurance company	USD $79
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $394
Amount paid for insurance broker fees	79
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 145598

Policy instance

Insurance contract or identification number	GL 145598
Number of Individuals Covered	117
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $627
Total amount of fees paid to insurance company	USD $175
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $627
Amount paid for insurance broker fees	175
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 160316

Policy instance

Insurance contract or identification number	G 160316
Number of Individuals Covered	140
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,535
Total amount of fees paid to insurance company	USD $892
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,535
Amount paid for insurance broker fees	892
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	FIRST INSURANCE SERVICES LC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 160316

Policy instance

Insurance contract or identification number	G 160316
Number of Individuals Covered	133
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $2,397
Total amount of fees paid to insurance company	USD $1,203
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 145598

Policy instance

Insurance contract or identification number	GL 145598
Number of Individuals Covered	110
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $574
Total amount of fees paid to insurance company	USD $194
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 119308

Policy instance

Insurance contract or identification number	LTD 119308
Number of Individuals Covered	23
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $366
Total amount of fees paid to insurance company	USD $84
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 181705

Policy instance

Insurance contract or identification number	VG 181705
Number of Individuals Covered	68
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $3,400
Total amount of fees paid to insurance company	USD $711
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	DEPEND LIFE VOLUNTARY DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $17,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )

Policy contract number

0QM1 052M

Policy instance

Insurance contract or identification number	0QM1 052M
Number of Individuals Covered	88
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $36,980
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $561,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )

Policy contract number

0QM1 052M

Policy instance

Insurance contract or identification number	0QM1 052M
Number of Individuals Covered	107
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $35,662
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $574,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,730
Insurance broker organization code?	3
Insurance broker name	MUTUAL MED INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 160316

Policy instance

Insurance contract or identification number	G 160316
Number of Individuals Covered	140
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,123
Total amount of fees paid to insurance company	USD $1,004
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,123
Amount paid for insurance broker fees	1004
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker name	FIRST INSURANCE SERVICE

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 145598

Policy instance

Insurance contract or identification number	GL 145598
Number of Individuals Covered	118
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $681
Total amount of fees paid to insurance company	USD $155
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $681
Amount paid for insurance broker fees	155
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker name	FIRST INSURANCE SERVICE

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 119308

Policy instance

Insurance contract or identification number	LTD 119308
Number of Individuals Covered	22
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $404
Total amount of fees paid to insurance company	USD $73
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $404
Amount paid for insurance broker fees	73
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker name	FIRST INSURANCE SERVICE

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 181705

Policy instance

Insurance contract or identification number	VG 181705
Number of Individuals Covered	77
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $4,317
Total amount of fees paid to insurance company	USD $326
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	DEPEND LIFE VOLUNTARY DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $21,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,317
Amount paid for insurance broker fees	326
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker name	FIRST INSURANCE SERVICE

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Company Name:	BARTELS LUTHERAN HOME
Employer identification number (EIN):	420752685
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Iowa Secretary of State Business Entities
Incorporation Date:	1950-10-31
Company Identification Number:	054771
Legal Registered Office Address:	1922 5TH AVENUE NW WAVERLY United States of America (USA) 50677