LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 401k Plan overview

Plan Name	LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN
Plan identification number	504

LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE 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

LESTER E. COX MEDICAL CENTERS has sponsored the creation of one or more 401k plans.

Company Name:	LESTER E. COX MEDICAL CENTERS
Employer identification number (EIN):	440577118
NAIC Classification:	622000
NAIC Description:	Hospitals

Additional information about LESTER E. COX MEDICAL CENTERS

Jurisdiction of Incorporation:	Arkansas Secretary of State
Incorporation Date:
Company Identification Number:	100117977

More information about LESTER E. COX MEDICAL CENTERS

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
504	2022-05-01
504	2021-05-01
504	2021-01-01
504	2020-01-01
504	2019-01-01
504	2018-01-01
504	2017-01-01	ANDREW HEDGPETH		ANDREW HEDGPETH	2018-07-23
504	2016-01-01	ANDREW HEDGPETH		ANDREW HEDGPETH	2017-07-31
504	2015-01-01	ANDREW HEDGPETH		ANDREW HEDGPETH	2016-07-28
504	2014-01-01	ANDREW HEDGPETH
504	2013-01-01	JOHN HURSH		JOHN HURSH	2014-09-16
504	2012-01-01	JOHN HURSH		JOHN HURSH	2013-07-30
504	2011-01-01	JOHN HURSH
504	2010-02-01	ANDREW HEDGPETH
504	2009-02-01	JOHN HURSH

Plan Statistics for LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN

401k plan membership statisitcs for LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN

Measure	Date	Value
2022: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	9,974
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	10,104
Number of retired or separated participants receiving benefits	2022-05-01	38
Number of other retired or separated participants entitled to future benefits	2022-05-01	134
Total of all active and inactive participants	2022-05-01	10,276
2021: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-05-01	10,019
Total number of active participants reported on line 7a of the Form 5500	2021-05-01	9,675
Number of retired or separated participants receiving benefits	2021-05-01	69
Number of other retired or separated participants entitled to future benefits	2021-05-01	195
Total of all active and inactive participants	2021-05-01	9,939
Total participants, beginning-of-year	2021-01-01	10,079
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	9,943
Number of retired or separated participants receiving benefits	2021-01-01	43
Number of other retired or separated participants entitled to future benefits	2021-01-01	253
Total of all active and inactive participants	2021-01-01	10,239
2020: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	9,939
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	9,997
Number of retired or separated participants receiving benefits	2020-01-01	21
Number of other retired or separated participants entitled to future benefits	2020-01-01	167
Total of all active and inactive participants	2020-01-01	10,185
2019: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	9,393
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	9,686
Number of retired or separated participants receiving benefits	2019-01-01	58
Number of other retired or separated participants entitled to future benefits	2019-01-01	149
Total of all active and inactive participants	2019-01-01	9,893
2018: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	8,922
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	9,075
Number of retired or separated participants receiving benefits	2018-01-01	28
Number of other retired or separated participants entitled to future benefits	2018-01-01	117
Total of all active and inactive participants	2018-01-01	9,220
2017: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	8,490
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	8,762
Number of retired or separated participants receiving benefits	2017-01-01	25
Number of other retired or separated participants entitled to future benefits	2017-01-01	128
Total of all active and inactive participants	2017-01-01	8,915
2016: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	8,110
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	8,365
Number of retired or separated participants receiving benefits	2016-01-01	37
Number of other retired or separated participants entitled to future benefits	2016-01-01	108
Total of all active and inactive participants	2016-01-01	8,510
2015: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	7,716
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	7,913
Number of retired or separated participants receiving benefits	2015-01-01	3
Number of other retired or separated participants entitled to future benefits	2015-01-01	42
Total of all active and inactive participants	2015-01-01	7,958
2014: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	6,406
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	6,265
Number of retired or separated participants receiving benefits	2014-01-01	62
Number of other retired or separated participants entitled to future benefits	2014-01-01	205
Total of all active and inactive participants	2014-01-01	6,532
2013: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	5,585
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	5,558
Number of retired or separated participants receiving benefits	2013-01-01	98
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	5,656
2012: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	6,493
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	6,418
Number of retired or separated participants receiving benefits	2012-01-01	64
Number of other retired or separated participants entitled to future benefits	2012-01-01	229
Total of all active and inactive participants	2012-01-01	6,711
2011: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	12,381
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	11,832
Number of retired or separated participants receiving benefits	2011-01-01	63
Number of other retired or separated participants entitled to future benefits	2011-01-01	253
Total of all active and inactive participants	2011-01-01	12,148
2010: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-02-01	11,852
Total number of active participants reported on line 7a of the Form 5500	2010-02-01	11,924
Number of retired or separated participants receiving benefits	2010-02-01	90
Number of other retired or separated participants entitled to future benefits	2010-02-01	256
Total of all active and inactive participants	2010-02-01	12,270
2009: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-02-01	4,788
Total number of active participants reported on line 7a of the Form 5500	2009-02-01	5,500
Number of retired or separated participants receiving benefits	2009-02-01	56
Number of other retired or separated participants entitled to future benefits	2009-02-01	62
Total of all active and inactive participants	2009-02-01	5,618
Total participants	2009-02-01	5,618

Form 5500 Responses for LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN

2022: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	Submission has been amended	No
2022-05-01	This submission is the final filing	No
2022-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-05-01	Plan is a collectively bargained plan	No
2022-05-01	Plan funding arrangement – Insurance	Yes
2022-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-05-01	Plan benefit arrangement – Insurance	Yes
2022-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2021 form 5500 responses
2021-05-01	Type of plan entity	Single employer plan
2021-05-01	Submission has been amended	No
2021-05-01	This submission is the final filing	No
2021-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-05-01	Plan is a collectively bargained plan	No
2021-05-01	Plan funding arrangement – Insurance	Yes
2021-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-05-01	Plan benefit arrangement – Insurance	Yes
2021-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-01-01	Plan is a collectively bargained plan	No
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: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
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: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2010 form 5500 responses
2010-02-01	Type of plan entity	Single employer plan
2010-02-01	Submission has been amended	No
2010-02-01	This submission is the final filing	No
2010-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2010-02-01	Plan is a collectively bargained plan	No
2010-02-01	Plan funding arrangement – Insurance	Yes
2010-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-02-01	Plan benefit arrangement – Insurance	Yes
2010-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: LESTER E COX MEDICAL CENTER WELFARE BENEFIT GROUP INSURANCE PLAN 2009 form 5500 responses
2009-02-01	Type of plan entity	Single employer plan
2009-02-01	Submission has been amended	No
2009-02-01	This submission is the final filing	No
2009-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-02-01	Plan is a collectively bargained plan	No
2009-02-01	Plan funding arrangement – Insurance	Yes
2009-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-02-01	Plan benefit arrangement – Insurance	Yes
2009-02-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	3
Insurance contract or identification number 12271063 Number of Individuals Covered 2942 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $7,250 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,250 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK0980347
Policy instance	1
Insurance contract or identification number LK0980347 Number of Individuals Covered 8090 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $188,504 Total amount of fees paid to insurance company USD $73,152 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,885,032 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $94,252 Insurance broker organization code? 3 Amount paid for insurance broker fees 45000 Additional information about fees paid to insurance broker OVERRIDE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	CI961010
Policy instance	2
Insurance contract or identification number CI961010 Number of Individuals Covered 5266 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $283,904 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $1,135,619 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $141,952 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	HC960446
Policy instance	11
Insurance contract or identification number HC960446 Number of Individuals Covered 1409 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $158,154 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY HOSPITAL CARE Welfare Benefit Premiums Paid to Carrier USD $655,270 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $79,077 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK0980348
Policy instance	4
Insurance contract or identification number LK0980348 Number of Individuals Covered 199 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $91,948 Total amount of fees paid to insurance company USD $58,272 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,046,573 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $45,974 Insurance broker organization code? 3 Amount paid for insurance broker fees 38301 Additional information about fees paid to insurance broker OVERRIDE
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADDS06031
Policy instance	5
Insurance contract or identification number ADDS06031 Number of Individuals Covered 217 Insurance policy start date 2021-06-01 Insurance policy end date 2022-05-31 Total amount of commissions paid to insurance broker USD $2,419 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $16,127 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,419 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX0980451
Policy instance	6
Insurance contract or identification number FLX0980451 Number of Individuals Covered 8049 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $165,846 Total amount of fees paid to insurance company USD $69,643 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,661,963 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $82,923 Insurance broker organization code? 3 Amount paid for insurance broker fees 45000 Additional information about fees paid to insurance broker SERVICE FEES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT980189
Policy instance	7
Insurance contract or identification number VDT980189 Number of Individuals Covered 4835 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $971,234 Total amount of fees paid to insurance company USD $95,425 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,028,526 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $467,668 Amount paid for insurance broker fees 45000 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK980465
Policy instance	8
Insurance contract or identification number OK980465 Number of Individuals Covered 8049 Insurance policy start date 2022-04-01 Insurance policy end date 2023-03-31 Total amount of commissions paid to insurance broker USD $15,914 Total amount of fees paid to insurance company USD $9,521 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $159,434 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,957 Amount paid for insurance broker fees 7166 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	028965
Policy instance	9
Insurance contract or identification number 028965 Number of Individuals Covered 4959 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $24,415 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $406,921 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,415 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	AI961052
Policy instance	10
Insurance contract or identification number AI961052 Number of Individuals Covered 4074 Insurance policy start date 2022-05-01 Insurance policy end date 2023-04-30 Total amount of commissions paid to insurance broker USD $261,972 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL INJURY Welfare Benefit Premiums Paid to Carrier USD $1,047,891 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $130,986 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK980347
Policy instance	4
Insurance contract or identification number LK980347 Number of Individuals Covered 7571 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $182,214 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,671,417 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $91,107 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	HC960446
Policy instance	3
Insurance contract or identification number HC960446 Number of Individuals Covered 1192 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $223,940 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY HOSPITAL CARE Welfare Benefit Premiums Paid to Carrier USD $610,505 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $111,970 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK980465
Policy instance	2
Insurance contract or identification number OK980465 Number of Individuals Covered 7562 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $15,504 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $142,121 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,752 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT980189
Policy instance	1
Insurance contract or identification number VDT980189 Number of Individuals Covered 4470 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $950,150 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,360,378 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $473,575 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	CI961010
Policy instance	5
Insurance contract or identification number CI961010 Number of Individuals Covered 4824 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $269,618 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $1,078,469 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $134,809 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	AI961052
Policy instance	7
Insurance contract or identification number AI961052 Number of Individuals Covered 3782 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $258,818 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL INJURY Welfare Benefit Premiums Paid to Carrier USD $1,035,271 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $129,409 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980451
Policy instance	8
Insurance contract or identification number FLX980451 Number of Individuals Covered 7562 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $162,014 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,485,660 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $81,007 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK980348
Policy instance	9
Insurance contract or identification number LK980348 Number of Individuals Covered 7571 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $76,630 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $705,007 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38,315 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADDS06031
Policy instance	10
Insurance contract or identification number ADDS06031 Number of Individuals Covered 229 Insurance policy start date 2020-06-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $2,665 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $17,764 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,665 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	11
Insurance contract or identification number 12271063 Number of Individuals Covered 2783 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $6,199 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,199 Insurance broker organization code? 3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	028965
Policy instance	6
Insurance contract or identification number 028965 Number of Individuals Covered 2732 Insurance policy start date 2021-05-01 Insurance policy end date 2022-04-30 Total amount of commissions paid to insurance broker USD $25,296 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $421,593 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,296 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	HC 960446
Policy instance	1
Insurance contract or identification number HC 960446 Number of Individuals Covered 1158 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $252,098 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY HOSPITAL CARE Welfare Benefit Premiums Paid to Carrier USD $524,544 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $126,049 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	AI 961052
Policy instance	6
Insurance contract or identification number AI 961052 Number of Individuals Covered 4053 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $264,016 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENTAL INJURY Welfare Benefit Premiums Paid to Carrier USD $978,534 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $132,008 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	5
Insurance contract or identification number 12271063 Number of Individuals Covered 2729 Insurance policy start date 2021-01-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $3,472 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,472 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX 980451
Policy instance	4
Insurance contract or identification number FLX 980451 Number of Individuals Covered 4408 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $154,876 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,548,750 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $77,438 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 980465
Policy instance	11
Insurance contract or identification number OK 980465 Number of Individuals Covered 8030 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $15,310 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $153,106 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,655 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980347
Policy instance	2
Insurance contract or identification number LK 980347 Number of Individuals Covered 8034 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $173,386 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,733,865 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $86,693 Insurance broker organization code? 3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	028965
Policy instance	7
Insurance contract or identification number 028965 Number of Individuals Covered 2928 Insurance policy start date 2021-01-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $11,036 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $180,648 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,036 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 980465
Policy instance	8
Insurance contract or identification number OK 980465 Number of Individuals Covered 8030 Insurance policy start date 2021-04-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $1,276 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $12,751 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $638 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	CI 961010
Policy instance	9
Insurance contract or identification number CI 961010 Number of Individuals Covered 5049 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $251,832 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $932,807 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $125,916 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX 980451
Policy instance	3
Insurance contract or identification number FLX 980451 Number of Individuals Covered 4408 Insurance policy start date 2021-04-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $13,420 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $134,200 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,710 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980348
Policy instance	15
Insurance contract or identification number LK 980348 Number of Individuals Covered 8034 Insurance policy start date 2021-04-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $5,932 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $59,319 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,966 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT 980189
Policy instance	14
Insurance contract or identification number VDT 980189 Number of Individuals Covered 4810 Insurance policy start date 2021-04-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $71,084 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $284,336 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35,542 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980347
Policy instance	13
Insurance contract or identification number LK 980347 Number of Individuals Covered 8034 Insurance policy start date 2021-04-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $14,884 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $148,831 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,442 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980348
Policy instance	12
Insurance contract or identification number LK 980348 Number of Individuals Covered 8034 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $69,900 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $699,009 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,950 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT 980189
Policy instance	10
Insurance contract or identification number VDT 980189 Number of Individuals Covered 4810 Insurance policy start date 2020-04-01 Insurance policy end date 2021-03-31 Total amount of commissions paid to insurance broker USD $911,610 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,646,439 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $455,805 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980347
Policy instance	1
Insurance contract or identification number LK 980347 Number of Individuals Covered 9406 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $145,824 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,458,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $72,912 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	CI 961010
Policy instance	2
Insurance contract or identification number CI 961010 Number of Individuals Covered 4698 Insurance policy start date 2019-06-01 Insurance policy end date 2020-05-31 Total amount of commissions paid to insurance broker USD $192,900 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $771,602 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $96,450 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADDS06031
Policy instance	3
Insurance contract or identification number ADDS06031 Number of Individuals Covered 219 Insurance policy start date 2019-06-01 Insurance policy end date 2020-05-31 Total amount of commissions paid to insurance broker USD $2,615 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $17,434 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,615 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	HC 960446
Policy instance	4
Insurance contract or identification number HC 960446 Number of Individuals Covered 791 Insurance policy start date 2019-06-01 Insurance policy end date 2020-05-31 Total amount of commissions paid to insurance broker USD $110,004 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided VOLUNTARY HOSPITAL CARE Welfare Benefit Premiums Paid to Carrier USD $200,009 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $55,002 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	AI 961052
Policy instance	5
Insurance contract or identification number AI 961052 Number of Individuals Covered 4030 Insurance policy start date 2019-06-01 Insurance policy end date 2020-05-31 Total amount of commissions paid to insurance broker USD $223,816 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided ACCIDENT INJURY Welfare Benefit Premiums Paid to Carrier USD $815,075 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $111,908 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX960451
Policy instance	6
Insurance contract or identification number FLX960451 Number of Individuals Covered 4206 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $125,378 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,253,772 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $62,689 Insurance broker organization code? 3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	7
Insurance contract or identification number 28965 Number of Individuals Covered 2932 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $25,604 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $426,737 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,604 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	8
Insurance contract or identification number 12271063 Number of Individuals Covered 2683 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $6,347 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,347 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 980465
Policy instance	9
Insurance contract or identification number OK 980465 Number of Individuals Covered 7797 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $12,516 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $125,165 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,258 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT980189
Policy instance	10
Insurance contract or identification number VDT980189 Number of Individuals Covered 4926 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $769,976 Total amount of fees paid to insurance company USD $0 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,079,907 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $384,988 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980348
Policy instance	11
Insurance contract or identification number LK 980348 Number of Individuals Covered 9406 Insurance policy start date 2019-04-01 Insurance policy end date 2020-03-31 Total amount of commissions paid to insurance broker USD $59,158 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $591,588 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,579 Insurance broker organization code? 3
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1813-0001
Policy instance	1
Insurance contract or identification number 1813-0001 Number of Individuals Covered 413 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $12,260 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $204,401 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,260 Insurance broker organization code? 3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	2
Insurance contract or identification number 28965 Number of Individuals Covered 2970 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $30,602 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $507,029 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,602 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701273
Policy instance	3
Insurance contract or identification number 701273 Number of Individuals Covered 4419 Insurance policy start date 2019-01-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $168,901 Total amount of fees paid to insurance company USD $13,512 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $675,604 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $84,451 Amount paid for insurance broker fees 6756 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	4
Insurance contract or identification number 12271063 Number of Individuals Covered 2488 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $6,111 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,111 Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0010784081
Policy instance	5
Insurance contract or identification number 0010784081 Number of Individuals Covered 44 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,336 Total amount of fees paid to insurance company USD $96 Other welfare benefits provided ACCIDENT, CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $5,059 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $668 Amount paid for insurance broker fees 88 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272
Policy instance	6
Insurance contract or identification number 701272 Number of Individuals Covered 7168 Insurance policy start date 2019-01-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $73,857 Total amount of fees paid to insurance company USD $14,772 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $738,570 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36,929 Amount paid for insurance broker fees 7386 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADDS06031
Policy instance	7
Insurance contract or identification number ADDS06031 Number of Individuals Covered 218 Insurance policy start date 2018-06-01 Insurance policy end date 2019-05-31 Total amount of commissions paid to insurance broker USD $2,538 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $16,919 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,538 Insurance broker organization code? 3
KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )
Policy contract number	54529S
Policy instance	8
Insurance contract or identification number 54529S Number of Individuals Covered 226 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $30,576 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $282,720 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,576 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701274
Policy instance	9
Insurance contract or identification number 701274 Number of Individuals Covered 174 Insurance policy start date 2019-01-01 Insurance policy end date 2019-03-31 Total amount of commissions paid to insurance broker USD $16,231 Total amount of fees paid to insurance company USD $3,246 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $162,312 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,116 Amount paid for insurance broker fees 1623 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272 0005
Policy instance	13
Insurance contract or identification number 701272 0005 Number of Individuals Covered 80 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $3,508 Total amount of fees paid to insurance company USD $1,020 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $35,083 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,754 Amount paid for insurance broker fees 510 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272 0004
Policy instance	14
Insurance contract or identification number 701272 0004 Number of Individuals Covered 57 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $848 Total amount of fees paid to insurance company USD $248 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,472 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $424 Amount paid for insurance broker fees 124 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701274 0001
Policy instance	15
Insurance contract or identification number 701274 0001 Number of Individuals Covered 177 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $62,362 Total amount of fees paid to insurance company USD $18,174 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $623,611 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31,181 Amount paid for insurance broker fees 9087 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADDS06031
Policy instance	16
Insurance contract or identification number ADDS06031 Number of Individuals Covered 253 Insurance policy start date 2017-06-01 Insurance policy end date 2018-05-31 Total amount of commissions paid to insurance broker USD $3,058 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $20,385 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,058 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272 0002
Policy instance	17
Insurance contract or identification number 701272 0002 Number of Individuals Covered 378 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $5,720 Total amount of fees paid to insurance company USD $1,686 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $57,207 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,860 Amount paid for insurance broker fees 843 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1813-0001
Policy instance	18
Insurance contract or identification number 1813-0001 Number of Individuals Covered 458 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $12,387 Total amount of fees paid to insurance company USD $523 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $204,756 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,387 Amount paid for insurance broker fees 523 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272 0008
Policy instance	19
Insurance contract or identification number 701272 0008 Number of Individuals Covered 17 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $307 Total amount of fees paid to insurance company USD $93 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,070 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $154 Amount paid for insurance broker fees 47 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	0283653
Policy instance	20
Insurance contract or identification number 0283653 Number of Individuals Covered 156 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $6,893 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 A D & D Welfare Benefit Premiums Paid to Carrier USD $68,318 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,893 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272 0001
Policy instance	21
Insurance contract or identification number 701272 0001 Number of Individuals Covered 5842 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $220,476 Total amount of fees paid to insurance company USD $65,383 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $2,204,765 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $110,238 Amount paid for insurance broker fees 32692 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )
Policy contract number	54529S
Policy instance	22
Insurance contract or identification number 54529S Number of Individuals Covered 229 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $30,025 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $278,318 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,025 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701273 0001
Policy instance	12
Insurance contract or identification number 701273 0001 Number of Individuals Covered 3619 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $600,077 Total amount of fees paid to insurance company USD $71,290 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,400,308 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $300,039 Amount paid for insurance broker fees 35645 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1903-2000
Policy instance	11
Insurance contract or identification number 1903-2000 Number of Individuals Covered 134 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $6,621 Total amount of fees paid to insurance company USD $174 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $62,228 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,621 Insurance broker organization code? 3 Amount paid for insurance broker fees 174 Additional information about fees paid to insurance broker BROKER BONUS
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	10
Insurance contract or identification number 28965 Number of Individuals Covered 2827 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $23,336 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $390,435 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,336 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272 0003
Policy instance	1
Insurance contract or identification number 701272 0003 Number of Individuals Covered 841 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $38,977 Total amount of fees paid to insurance company USD $11,598 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $389,772 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,489 Amount paid for insurance broker fees 5799 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701273 0002
Policy instance	2
Insurance contract or identification number 701273 0002 Number of Individuals Covered 515 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $88,208 Total amount of fees paid to insurance company USD $10,430 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $352,833 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44,104 Amount paid for insurance broker fees 5215 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5479045
Policy instance	3
Insurance contract or identification number 5479045 Number of Individuals Covered 96 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $5,472 Total amount of fees paid to insurance company USD $5,830 Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $92,275 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,928 Amount paid for insurance broker fees 5830 Additional information about fees paid to insurance broker BONUS COMMISSIONS Insurance broker organization code? 3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0010784081
Policy instance	4
Insurance contract or identification number 0010784081 Number of Individuals Covered 43 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,436 Total amount of fees paid to insurance company USD $113 Other welfare benefits provided ACCIDENT, CRITICAL ILLNESS Welfare Benefit Premiums Paid to Carrier USD $10,698 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $659 Amount paid for insurance broker fees 47 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272 0006
Policy instance	5
Insurance contract or identification number 701272 0006 Number of Individuals Covered 7 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $130 Total amount of fees paid to insurance company USD $38 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,304 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $65 Amount paid for insurance broker fees 19 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701273 0004
Policy instance	6
Insurance contract or identification number 701273 0004 Number of Individuals Covered 140 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $22,324 Total amount of fees paid to insurance company USD $2,650 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $89,304 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,162 Amount paid for insurance broker fees 1325 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701273 0003
Policy instance	7
Insurance contract or identification number 701273 0003 Number of Individuals Covered 39 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $7,420 Total amount of fees paid to insurance company USD $874 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $29,678 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,710 Amount paid for insurance broker fees 437 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	8
Insurance contract or identification number 12271063 Number of Individuals Covered 2157 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $5,688 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,688 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272 0007
Policy instance	9
Insurance contract or identification number 701272 0007 Number of Individuals Covered 249 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $8,976 Total amount of fees paid to insurance company USD $2,674 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $89,761 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,488 Amount paid for insurance broker fees 1337 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	1
Insurance contract or identification number 28965 Number of Individuals Covered 5515 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $26,287 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $441,329 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $26,287 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICES INC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADDS06031
Policy instance	2
Insurance contract or identification number ADDS06031 Number of Individuals Covered 249 Insurance policy start date 2016-06-01 Insurance policy end date 2017-05-31 Total amount of commissions paid to insurance broker USD $3,886 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $25,908 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,886 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701273
Policy instance	3
Insurance contract or identification number 701273 Number of Individuals Covered 3919 Insurance policy start date 2017-04-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $421,388 Total amount of fees paid to insurance company USD $84,278 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,685,555 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $210,694 Amount paid for insurance broker fees 42139 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name BCINSOURCING, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	4
Insurance contract or identification number 12271063 Number of Individuals Covered 1913 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $5,211 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,211 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701272
Policy instance	5
Insurance contract or identification number 701272 Number of Individuals Covered 6498 Insurance policy start date 2017-04-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $174,628 Total amount of fees paid to insurance company USD $87,314 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $1,746,282 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $87,314 Amount paid for insurance broker fees 43657 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name BCINSOURCING, LLC
KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )
Policy contract number	54529S
Policy instance	6
Insurance contract or identification number 54529S Number of Individuals Covered 243 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $30,693 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $260,326 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,693 Insurance broker organization code? 3 Insurance broker name MICHAEL A SCOTT
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00509465
Policy instance	7
Insurance contract or identification number 00509465 Number of Individuals Covered 125 Insurance policy start date 2017-01-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $7,470 Total amount of fees paid to insurance company USD $13,966 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $76,616 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,470 Amount paid for insurance broker fees 13966 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	701274
Policy instance	8
Insurance contract or identification number 701274 Number of Individuals Covered 127 Insurance policy start date 2017-04-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $31,516 Total amount of fees paid to insurance company USD $15,758 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $315,153 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,758 Amount paid for insurance broker fees 7879 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION PAID Insurance broker organization code? 3 Insurance broker name BCINSOURCING, LLC
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1813-1000
Policy instance	9
Insurance contract or identification number 1813-1000 Number of Individuals Covered 468 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $14,305 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $210,687 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,305 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00494886
Policy instance	10
Insurance contract or identification number 00494886 Number of Individuals Covered 6493 Insurance policy start date 2017-01-01 Insurance policy end date 2017-03-31 Total amount of commissions paid to insurance broker USD $229,402 Total amount of fees paid to insurance company USD $48,705 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $1,293,750 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $118,035 Amount paid for insurance broker fees 48705 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3 Insurance broker name BCINSOURCING LLC
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1903-2000
Policy instance	11
Insurance contract or identification number 1903-2000 Number of Individuals Covered 120 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $6,590 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $64,229 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,590 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	2
Insurance contract or identification number 28965 Number of Individuals Covered 5112 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $19,317 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $324,343 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,317 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract number	G 00608841
Policy instance	3
Insurance contract or identification number G 00608841 Number of Individuals Covered 248 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $42,127 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $280,847 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $42,127 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON INC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADDS06031
Policy instance	4
Insurance contract or identification number ADDS06031 Number of Individuals Covered 295 Insurance policy start date 2014-06-01 Insurance policy end date 2015-05-31 Total amount of commissions paid to insurance broker USD $4,351 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $29,006 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,351 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00494886
Policy instance	5
Insurance contract or identification number 00494886 Number of Individuals Covered 7679 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $741,607 Total amount of fees paid to insurance company USD $87,014 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $4,645,845 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $125,079 Amount paid for insurance broker fees 87014 Additional information about fees paid to insurance broker FEES PAID Insurance broker organization code? 3 Insurance broker name HEALTH & BENEFIT SYSTEMS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	00509465
Policy instance	6
Insurance contract or identification number 00509465 Number of Individuals Covered 121 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $44,098 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 A D & D Welfare Benefit Premiums Paid to Carrier USD $449,656 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,607 Insurance broker organization code? 3 Insurance broker name WOODY FINANCIAL GROUP INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	1
Insurance contract or identification number 12271063 Number of Individuals Covered 1628 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $4,902 Total amount of fees paid to insurance company USD $2 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,902 Amount paid for insurance broker fees 2 Additional information about fees paid to insurance broker OUTSTANDING COMMISSIONS/FEES Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON INC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	207543OGL
Policy instance	8
Insurance contract or identification number 207543OGL Number of Individuals Covered 81 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,921 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $37,888 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,921 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON INC
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1813-1000
Policy instance	7
Insurance contract or identification number 1813-1000 Number of Individuals Covered 471 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $14,620 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $222,864 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,620 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract number	G 00608841
Policy instance	6
Insurance contract or identification number G 00608841 Number of Individuals Covered 284 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $39,801 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $265,342 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39,801 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON INC
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	7
Insurance contract or identification number 28965 Number of Individuals Covered 4687 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $17,970 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $300,601 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,970 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010157325
Policy instance	5
Insurance contract or identification number 000010157325 Number of Individuals Covered 6037 Insurance policy start date 2014-01-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $5,704 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $148,512 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,704 Insurance broker organization code? 3 Insurance broker name VHA MID AMERICA INS SERVICES
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675739-GRH
Policy instance	3
Insurance contract or identification number 675739-GRH Number of Individuals Covered 3282 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $436,576 Total amount of fees paid to insurance company USD $43,048 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,455,701 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $218,288 Amount paid for insurance broker fees 43048 Additional information about fees paid to insurance broker BONUS PAID Insurance broker organization code? 3 Insurance broker name HEALTH AND BENEFIT SYSTEM INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	4
Insurance contract or identification number 12271063 Number of Individuals Covered 1558 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,850 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,850 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON INC
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1813-1000
Policy instance	2
Insurance contract or identification number 1813-1000 Number of Individuals Covered 518 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $16,213 Total amount of fees paid to insurance company USD $0 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $233,799 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,213 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010157326
Policy instance	1
Insurance contract or identification number 000010157326 Number of Individuals Covered 5961 Insurance policy start date 2014-01-01 Insurance policy end date 2014-03-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $220,209 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	207543-OGL
Policy instance	8
Insurance contract or identification number 207543-OGL Number of Individuals Covered 81 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $3,992 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $40,099 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 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	8
Insurance contract or identification number 12271063 Number of Individuals Covered 1111 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $9,050 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 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 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,050 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010157326
Policy instance	2
Insurance contract or identification number 000010157326 Number of Individuals Covered 6007 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $28,239 Total amount of fees paid to insurance company USD $25,000 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 $1,147,684 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,239 Amount paid for insurance broker fees 25000 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name VHA MID AMERICA INSURANCE SERVICES
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010157325
Policy instance	1
Insurance contract or identification number 000010157325 Number of Individuals Covered 5981 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $38,097 Total amount of fees paid to insurance company USD $33,672 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 A D & D 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 $755,573 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38,097 Amount paid for insurance broker fees 33672 Additional information about fees paid to insurance broker BROKER BONUS Insurance broker organization code? 3 Insurance broker name VHA MID AMERICA INSURANCE SERVICES
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1813-1000
Policy instance	3
Insurance contract or identification number 1813-1000 Number of Individuals Covered 464 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $13,209 Total amount of fees paid to insurance company USD $516 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 $221,555 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,209 Amount paid for insurance broker fees 516 Additional information about fees paid to insurance broker DELTA REWARDS Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675739GRH
Policy instance	4
Insurance contract or identification number 675739GRH Number of Individuals Covered 3002 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $419,154 Total amount of fees paid to insurance company USD $64,162 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 $1,397,254 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $209,577 Amount paid for insurance broker fees 64162 Additional information about fees paid to insurance broker BONUS PAID Insurance broker organization code? 3 Insurance broker name HEALTH & BENEFIT SYSTEM INC
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract number	G 00608841
Policy instance	5
Insurance contract or identification number G 00608841 Number of Individuals Covered 278 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $38,028 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 Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided A D & D 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 $253,520 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38,028 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON, INC
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	6
Insurance contract or identification number 28965 Number of Individuals Covered 4529 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $16,425 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 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 $296,006 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,425 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	207543-OGL
Policy instance	7
Insurance contract or identification number 207543-OGL Number of Individuals Covered 83 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $3,706 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 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 $39,864 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,706 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON INC
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	9
Insurance contract or identification number 28965 Number of Individuals Covered 4572 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $18,856 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $303,113 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,856 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	473227
Policy instance	10
Insurance contract or identification number 473227 Number of Individuals Covered 5522 Insurance policy start date 2012-01-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $33,286 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 A D & D Welfare Benefit Premiums Paid to Carrier USD $686,318 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $33,286 Insurance broker organization code? 3 Insurance broker name VHA MID-AMERICA INSURANCE SERVICES
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1813-1000
Policy instance	8
Insurance contract or identification number 1813-1000 Number of Individuals Covered 444 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $12,406 Total amount of fees paid to insurance company USD $538 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,406 Amount paid for insurance broker fees 538 Additional information about fees paid to insurance broker DELTA REWARDS Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	207543-OGL
Policy instance	7
Insurance contract or identification number 207543-OGL Number of Individuals Covered 105 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $3,758 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $29,339 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,758 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675739-GRH
Policy instance	6
Insurance contract or identification number 675739-GRH Number of Individuals Covered 2665 Insurance policy start date 2011-06-01 Insurance policy end date 2012-05-31 Total amount of commissions paid to insurance broker USD $396,832 Total amount of fees paid to insurance company USD $37,973 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,322,989 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $198,416 Amount paid for insurance broker fees 37973 Insurance broker organization code? 3 Insurance broker name HEALTH AND BENEFIT SYSTEM INC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADD-S06031
Policy instance	1
Insurance contract or identification number ADD-S06031 Number of Individuals Covered 335 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $4,043 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $26,952 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,043 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010157325
Policy instance	5
Insurance contract or identification number 000010157325 Number of Individuals Covered 4992 Insurance policy start date 2012-05-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $44,955 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $449,546 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44,955 Insurance broker organization code? 3 Insurance broker name VHA MID AMERICA INS SERVICES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	4
Insurance contract or identification number 12271063 Number of Individuals Covered 883 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $8,325 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,325 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON INC
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract number	G 00608841
Policy instance	3
Insurance contract or identification number G 00608841 Number of Individuals Covered 264 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $32,789 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $218,590 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32,789 Insurance broker organization code? 3 Insurance broker name BARKER-PHILLIPS-JACKSON
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010157326
Policy instance	2
Insurance contract or identification number 000010157326 Number of Individuals Covered 4779 Insurance policy start date 2012-05-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $75,125 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $751,247 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $75,125 Insurance broker organization code? 3 Insurance broker name VHA MID AMERICA INS SRERVICES
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	473227
Policy instance	4
Insurance contract or identification number 473227 Number of Individuals Covered 5560 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $103,344 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $2,055,406 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675739-GRH
Policy instance	2
Insurance contract or identification number 675739-GRH Number of Individuals Covered 2572 Insurance policy start date 2010-06-01 Insurance policy end date 2011-05-31 Total amount of commissions paid to insurance broker USD $365,896 Total amount of fees paid to insurance company USD $29,042 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,266,428 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	207543-OGL
Policy instance	5
Insurance contract or identification number 207543-OGL Number of Individuals Covered 71 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $3,872 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $37,253 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
Policy contract number	1813-1000
Policy instance	6
Insurance contract or identification number 1813-1000 Number of Individuals Covered 121 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $12,977 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
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	7
Insurance contract or identification number 28965 Number of Individuals Covered 4723 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $11,558 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $289,898 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: 32395 )
Policy contract number	12271063
Policy instance	3
Insurance contract or identification number 12271063 Number of Individuals Covered 829 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $8,134 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ADD-S06031
Policy instance	1
Insurance contract or identification number ADD-S06031 Number of Individuals Covered 360 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $4,575 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $30,503 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract number	G 00608841
Policy instance	8
Insurance contract or identification number G 00608841 Number of Individuals Covered 254 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $31,962 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $213,084 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number	28965
Policy instance	4
Insurance contract or identification number 28965 Number of Individuals Covered 4470 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $15,736 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $243,875 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,060 Insurance broker organization code? 3 Insurance broker name GALLAGHER BENEFIT SERVICE
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675739G
Policy instance	1
Insurance contract or identification number 675739G Number of Individuals Covered 5007 Insurance policy start date 2009-06-01 Insurance policy end date 2010-05-31 Total amount of commissions paid to insurance broker USD $347,368 Total amount of fees paid to insurance company USD $31,498 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,109,948 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $173,684 Amount paid for insurance broker fees 31498 Additional information about fees paid to insurance broker BONUS PAID Insurance broker organization code? 3 Insurance broker name HEALTH AND BENEFIT SYSTEM INC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675739-OGL
Policy instance	5
Insurance contract or identification number 675739-OGL Number of Individuals Covered 6406 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $139 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Other welfare benefits provided A D & D Welfare Benefit Premiums Paid to Carrier USD $60,477 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $139 Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675739-GRH
Policy instance	2
Insurance contract or identification number 675739-GRH Number of Individuals Covered 6406 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of fees paid to insurance company USD $31,498 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $106,316 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 31498 Additional information about fees paid to insurance broker BONUS PAID Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number	12271063
Policy instance	3
Insurance contract or identification number 12271063 Number of Individuals Covered 837 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $10,015 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,015 Insurance broker organization code? 3 Insurance broker name BARKER PHILLIPS JACKSON INC

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