401k Plan data: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN plan

RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN
Plan identification number	501

RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

RYDELL AUTO CENTER INC has sponsored the creation of one or more 401k plans.

Company Name: RYDELL AUTO CENTER INC

Employer identification number (EIN): 450236743

NAIC Classification: 441110
NAIC Description: New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 JERI SCHMIESS PENAS 2023-10-16
501 2021-01-01 JERI SCHMIESS PENAS 2022-10-14
501 2020-01-01 JERI SCHMIESS PENAS 2021-10-12
501 2019-01-01 JERI SCHMIESS PENAS 2020-09-10
501 2018-01-01 JERI SCHMIESS PENAS 2019-09-27
501 2017-01-01 JERI SCHMIESS PENAS
501 2016-01-01 JERI SCHMIESS PENAS
501 2015-01-01 JERI SCHMIESS PENAS
501 2014-01-01 JERI SCHMIESS PENAS
501 2013-01-01 JERI SCHMIESS PENAS
501 2012-01-01 JERI SCHMIESS PENAS
501 2011-01-01 JERI SCHMIESS PENAS
501 2010-01-01 GREG SORUM
501 2009-01-01 JERI SCHMIESS PENAS
501 2008-01-01 JERI SCHMIESS PENAS
501 2007-01-01 JERI SCHMIESS PENAS
501 2006-01-01 JERI SCHMIESS PENAS
501 2005-01-01 JERI SCHMIESS PENAS

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	JERI SCHMIESS PENAS	2023-10-16
501	2021-01-01	JERI SCHMIESS PENAS	2022-10-14
501	2020-01-01	JERI SCHMIESS PENAS	2021-10-12
501	2019-01-01	JERI SCHMIESS PENAS	2020-09-10
501	2018-01-01	JERI SCHMIESS PENAS	2019-09-27
501	2017-01-01	JERI SCHMIESS PENAS
501	2016-01-01	JERI SCHMIESS PENAS
501	2015-01-01	JERI SCHMIESS PENAS
501	2014-01-01	JERI SCHMIESS PENAS
501	2013-01-01	JERI SCHMIESS PENAS
501	2012-01-01	JERI SCHMIESS PENAS
501	2011-01-01	JERI SCHMIESS PENAS
501	2010-01-01	GREG SORUM
501	2009-01-01	JERI SCHMIESS PENAS
501	2008-01-01	JERI SCHMIESS PENAS
501	2007-01-01	JERI SCHMIESS PENAS
501	2006-01-01	JERI SCHMIESS PENAS
501	2005-01-01	JERI SCHMIESS PENAS

Plan Statistics for RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN

401k plan membership statisitcs for RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN

Measure Date Value
2022: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 217
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 217
Number of retired or separated participants receiving benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 217
2021: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 227
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 195
Number of retired or separated participants receiving benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 195
2020: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 278
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 251
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 251
2019: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 275
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 277
Number of retired or separated participants receiving benefits 2019-01-01 1
Total of all active and inactive participants 2019-01-01 278
2018: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 221
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 245
Number of retired or separated participants receiving benefits 2018-01-01 1
Total of all active and inactive participants 2018-01-01 246
2017: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 217
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 196
Number of retired or separated participants receiving benefits 2017-01-01 3
Total of all active and inactive participants 2017-01-01 199
2016: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 243
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 225
Number of retired or separated participants receiving benefits 2016-01-01 1
Total of all active and inactive participants 2016-01-01 226
2015: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 221
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 219
Number of retired or separated participants receiving benefits 2015-01-01 1
Total of all active and inactive participants 2015-01-01 220
2014: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 253
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 211
Number of retired or separated participants receiving benefits 2014-01-01 1
Total of all active and inactive participants 2014-01-01 212
2013: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 233
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 240
Number of retired or separated participants receiving benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 240
2012: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 240
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 177
Number of retired or separated participants receiving benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 178
2011: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 185
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 194
Number of retired or separated participants receiving benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 195
2010: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 177
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 172
Number of retired or separated participants receiving benefits 2010-01-01 4
Total of all active and inactive participants 2010-01-01 176
2009: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 140
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 138
Number of retired or separated participants receiving benefits 2009-01-01 5
Total of all active and inactive participants 2009-01-01 143
2008: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year 2008-01-01 161
Total number of active participants reported on line 7a of the Form 5500 2008-01-01 135
Number of retired or separated participants receiving benefits 2008-01-01 5
Total of all active and inactive participants 2008-01-01 140
2007: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2007 401k membership
Total participants, beginning-of-year 2007-01-01 152
Total number of active participants reported on line 7a of the Form 5500 2007-01-01 154
Number of retired or separated participants receiving benefits 2007-01-01 7
Total of all active and inactive participants 2007-01-01 161
2006: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2006 401k membership
Total participants, beginning-of-year 2006-01-01 160
Total number of active participants reported on line 7a of the Form 5500 2006-01-01 147
Number of retired or separated participants receiving benefits 2006-01-01 11
Total of all active and inactive participants 2006-01-01 158
2005: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2005 401k membership
Total participants, beginning-of-year 2005-01-01 172
Total number of active participants reported on line 7a of the Form 5500 2005-01-01 157
Total of all active and inactive participants 2005-01-01 157

Measure	Date	Value
2022: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	217
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	217
Number of retired or separated participants receiving benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	217
2021: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	227
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	195
Number of retired or separated participants receiving benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	195
2020: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	278
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	251
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	251
2019: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	275
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	277
Number of retired or separated participants receiving benefits	2019-01-01	1
Total of all active and inactive participants	2019-01-01	278
2018: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	221
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	245
Number of retired or separated participants receiving benefits	2018-01-01	1
Total of all active and inactive participants	2018-01-01	246
2017: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	217
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	196
Number of retired or separated participants receiving benefits	2017-01-01	3
Total of all active and inactive participants	2017-01-01	199
2016: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	243
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	225
Number of retired or separated participants receiving benefits	2016-01-01	1
Total of all active and inactive participants	2016-01-01	226
2015: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	221
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	219
Number of retired or separated participants receiving benefits	2015-01-01	1
Total of all active and inactive participants	2015-01-01	220
2014: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	253
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	211
Number of retired or separated participants receiving benefits	2014-01-01	1
Total of all active and inactive participants	2014-01-01	212
2013: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	233
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	240
Number of retired or separated participants receiving benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	240
2012: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	240
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	177
Number of retired or separated participants receiving benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	178
2011: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	185
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	194
Number of retired or separated participants receiving benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	195
2010: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	177
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	172
Number of retired or separated participants receiving benefits	2010-01-01	4
Total of all active and inactive participants	2010-01-01	176
2009: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	140
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	138
Number of retired or separated participants receiving benefits	2009-01-01	5
Total of all active and inactive participants	2009-01-01	143
2008: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year	2008-01-01	161
Total number of active participants reported on line 7a of the Form 5500	2008-01-01	135
Number of retired or separated participants receiving benefits	2008-01-01	5
Total of all active and inactive participants	2008-01-01	140
2007: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2007 401k membership
Total participants, beginning-of-year	2007-01-01	152
Total number of active participants reported on line 7a of the Form 5500	2007-01-01	154
Number of retired or separated participants receiving benefits	2007-01-01	7
Total of all active and inactive participants	2007-01-01	161
2006: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2006 401k membership
Total participants, beginning-of-year	2006-01-01	160
Total number of active participants reported on line 7a of the Form 5500	2006-01-01	147
Number of retired or separated participants receiving benefits	2006-01-01	11
Total of all active and inactive participants	2006-01-01	158
2005: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2005 401k membership
Total participants, beginning-of-year	2005-01-01	172
Total number of active participants reported on line 7a of the Form 5500	2005-01-01	157
Total of all active and inactive participants	2005-01-01	157

Form 5500 Responses for RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN

2022: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2008: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2008 form 5500 responses
2008-01-01	Type of plan entity	Single employer plan
2008-01-01	This submission is the final filing	No
2008-01-01	Plan funding arrangement – Insurance	Yes
2008-01-01	Plan benefit arrangement – Insurance	Yes
2007: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2007 form 5500 responses
2007-01-01	Type of plan entity	Single employer plan
2007-01-01	This submission is the final filing	No
2007-01-01	Plan funding arrangement – Insurance	Yes
2007-01-01	Plan benefit arrangement – Insurance	Yes
2006: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2006 form 5500 responses
2006-01-01	Type of plan entity	Single employer plan
2006-01-01	This submission is the final filing	No
2006-01-01	Plan funding arrangement – Insurance	Yes
2006-01-01	Plan benefit arrangement – Insurance	Yes
2005: RYDELL AUTO CENTER INC WELFARE BENEFIT PLAN 2005 form 5500 responses
2005-01-01	Type of plan entity	Single employer plan
2005-01-01	This submission is the final filing	No
2005-01-01	Plan funding arrangement – Insurance	Yes
2005-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

5976297

Policy instance

Insurance contract or identification number	5976297
Number of Individuals Covered	264
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $11,182
Total amount of fees paid to insurance company	USD $5,218
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,455
Insurance broker organization code?	3
Amount paid for insurance broker fees	1491
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

009413

Policy instance

Insurance contract or identification number	009413
Number of Individuals Covered	148
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $3,772
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3772
Additional information about fees paid to insurance broker	SERVICE FEE, BONUS
Insurance broker organization code?	3

SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )

Policy contract number

HP040636

Policy instance

Insurance contract or identification number	HP040636
Number of Individuals Covered	315
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,510,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5976297

Policy instance

Insurance contract or identification number	5976297
Number of Individuals Covered	264
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $1,949
Total amount of fees paid to insurance company	USD $910
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,299
Insurance broker organization code?	3
Amount paid for insurance broker fees	260
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

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

Policy contract number

0233567

Policy instance

Insurance contract or identification number	0233567
Number of Individuals Covered	67
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $4,421
Total amount of fees paid to insurance company	USD $1,238
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CII
Welfare Benefit Premiums Paid to Carrier	USD $21,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,537
Insurance broker organization code?	3
Amount paid for insurance broker fees	354
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

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

Policy contract number

0233568

Policy instance

Insurance contract or identification number	0233568
Number of Individuals Covered	130
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $2,703
Total amount of fees paid to insurance company	USD $757
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $12,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,162
Insurance broker organization code?	3
Amount paid for insurance broker fees	216
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

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

Policy contract number

0233569

Policy instance

Insurance contract or identification number	0233569
Number of Individuals Covered	25
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $2,665
Total amount of fees paid to insurance company	USD $746
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HOSPITAL CONFINEMENT
Welfare Benefit Premiums Paid to Carrier	USD $12,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,132
Insurance broker organization code?	3
Amount paid for insurance broker fees	213
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

226602

Policy instance

Insurance contract or identification number	226602
Number of Individuals Covered	282
Insurance policy start date	2021-01-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $567
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $567
Insurance broker organization code?	3

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

Policy contract number

471167

Policy instance

Insurance contract or identification number	471167
Number of Individuals Covered	116
Insurance policy start date	2021-01-01
Insurance policy end date	2021-03-01
Total amount of commissions paid to insurance broker	USD $2,063
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,063
Insurance broker organization code?	3

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

Policy contract number

471168

Policy instance

Insurance contract or identification number	471168
Number of Individuals Covered	84
Insurance policy start date	2021-01-01
Insurance policy end date	2021-03-01
Total amount of commissions paid to insurance broker	USD $711
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $711
Insurance broker organization code?	3

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

Policy contract number

0011369166

Policy instance

Insurance contract or identification number	0011369166
Number of Individuals Covered	36
Insurance policy start date	2021-01-01
Insurance policy end date	2021-03-01
Total amount of commissions paid to insurance broker	USD $479
Total amount of fees paid to insurance company	USD $17
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $287
Amount paid for insurance broker fees	17
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

30088308

Policy instance

Insurance contract or identification number	30088308
Number of Individuals Covered	119
Insurance policy start date	2021-01-01
Insurance policy end date	2021-02-28
Total amount of commissions paid to insurance broker	USD $346
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $346
Insurance broker organization code?	3

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

Policy contract number

R0677898

Policy instance

Insurance contract or identification number	R0677898
Number of Individuals Covered	192
Insurance policy start date	2021-01-01
Insurance policy end date	2021-03-01
Total amount of commissions paid to insurance broker	USD $878
Total amount of fees paid to insurance company	USD $24
Other welfare benefits provided	GRP HSP VOL,GRP ACC VOL, GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $8,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $416
Insurance broker organization code?	3
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )

Policy contract number

HP040636

Policy instance

Insurance contract or identification number	HP040636
Number of Individuals Covered	286
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,473,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0677898

Policy instance

Insurance contract or identification number	R0677898
Number of Individuals Covered	244
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,558
Total amount of fees paid to insurance company	USD $208
Other welfare benefits provided	GRP HSP VOL,GRP ACC VOL, GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $56,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,176
Amount paid for insurance broker fees	208
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

226602

Policy instance

Insurance contract or identification number	226602
Number of Individuals Covered	287
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,839
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,839
Insurance broker organization code?	3

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

Policy contract number

471167

Policy instance

Insurance contract or identification number	471167
Number of Individuals Covered	120
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,553
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,161
Insurance broker organization code?	3

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

Policy contract number

471168

Policy instance

Insurance contract or identification number	471168
Number of Individuals Covered	85
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,290
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $28,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,503
Insurance broker organization code?	3

SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )

Policy contract number

HP040636

Policy instance

Insurance contract or identification number	HP040636
Number of Individuals Covered	322
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,625,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0011369166

Policy instance

Insurance contract or identification number	0011369166
Number of Individuals Covered	90
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,041
Total amount of fees paid to insurance company	USD $115
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,425
Amount paid for insurance broker fees	115
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

30088308

Policy instance

Insurance contract or identification number	30088308
Number of Individuals Covered	122
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,105
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,066
Insurance broker organization code?	3

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

Policy contract number

0011369166

Policy instance

Insurance contract or identification number	0011369166
Number of Individuals Covered	94
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,586
Total amount of fees paid to insurance company	USD $129
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,752
Amount paid for insurance broker fees	129
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )

Policy contract number

HP040636

Policy instance

Insurance contract or identification number	HP040636
Number of Individuals Covered	378
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,528,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0677898

Policy instance

Insurance contract or identification number	R0677898
Number of Individuals Covered	240
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,105
Total amount of fees paid to insurance company	USD $236
Other welfare benefits provided	GRP HSP VOL,GRP ACC VOL, GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $57,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,267
Amount paid for insurance broker fees	236
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

471168

Policy instance

Insurance contract or identification number	471168
Number of Individuals Covered	86
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,250
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $28,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,250
Insurance broker organization code?	3

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

Policy contract number

471167

Policy instance

Insurance contract or identification number	471167
Number of Individuals Covered	126
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $12,404
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $82,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,404
Insurance broker organization code?	3

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

Policy contract number

50790-1723

Policy instance

Insurance contract or identification number	50790-1723
Number of Individuals Covered	171
Insurance policy start date	2019-01-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $317
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $317
Insurance broker organization code?	3

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

226602

Policy instance

Insurance contract or identification number	226602
Number of Individuals Covered	315
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,032
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,032
Insurance broker organization code?	3

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

Policy contract number

30088308

Policy instance

Insurance contract or identification number	30088308
Number of Individuals Covered	121
Insurance policy start date	2019-03-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,918
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,918
Insurance broker organization code?	3

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

0000491084

Policy instance

Insurance contract or identification number	0000491084
Number of Individuals Covered	282
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,217
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,217
Insurance broker organization code?	3

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

Policy contract number

0011369166

Policy instance

Insurance contract or identification number	0011369166
Number of Individuals Covered	91
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $11,401
Total amount of fees paid to insurance company	USD $385
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,841
Amount paid for insurance broker fees	385
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

SANFORD HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95683 )

Policy contract number

HP040636

Policy instance

Insurance contract or identification number	HP040636
Number of Individuals Covered	333
Insurance policy start date	2018-03-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,159,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0677898

Policy instance

Insurance contract or identification number	R0677898
Number of Individuals Covered	230
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $16,037
Total amount of fees paid to insurance company	USD $759
Other welfare benefits provided	GRP HSP VOL,GRP ACC VOL, GCIEE
Welfare Benefit Premiums Paid to Carrier	USD $61,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,625
Amount paid for insurance broker fees	759
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

471168

Policy instance

Insurance contract or identification number	471168
Number of Individuals Covered	78
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,147
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $29,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,147
Insurance broker organization code?	3

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

Policy contract number

471167

Policy instance

Insurance contract or identification number	471167
Number of Individuals Covered	91
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $11,974
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,974
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )

Policy contract number

68651+

Policy instance

Insurance contract or identification number	68651+
Number of Individuals Covered	302
Insurance policy start date	2018-01-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

50790-1723

Policy instance

Insurance contract or identification number	50790-1723
Number of Individuals Covered	173
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,860
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,860
Insurance broker organization code?	3

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

0000491084

Policy instance

Insurance contract or identification number	0000491084
Number of Individuals Covered	270
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,683
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,683
Insurance broker organization code?	3
Insurance broker name	JOSEPH EDWARD HUGUELET III

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

Policy contract number

50790-1723

Policy instance

Insurance contract or identification number	50790-1723
Number of Individuals Covered	180
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,732
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,732
Insurance broker organization code?	3
Insurance broker name	JOSEPH HUGUELET

BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )

Policy contract number

68651+

Policy instance

Insurance contract or identification number	68651+
Number of Individuals Covered	302
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,195,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

471167

Policy instance

Insurance contract or identification number	471167
Number of Individuals Covered	122
Insurance policy start date	2017-03-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9,516
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,516
Insurance broker organization code?	3
Insurance broker name	JOSEPH EDWARD HUGUELET III

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

Policy contract number

471168

Policy instance

Insurance contract or identification number	471168
Number of Individuals Covered	90
Insurance policy start date	2017-03-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,237
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $29,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,237
Insurance broker organization code?	3
Insurance broker name	JOSEPH EDWARD HUGUELET III

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

Policy contract number

R0677898

Policy instance

Insurance contract or identification number	R0677898
Number of Individuals Covered	180
Insurance policy start date	2017-03-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $28,892
Total amount of fees paid to insurance company	USD $1,573
Other welfare benefits provided	GRP HSP VOL,GRP ACC VOL, GCI
Welfare Benefit Premiums Paid to Carrier	USD $49,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,337
Amount paid for insurance broker fees	1573
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JOSEPH EDWARD HUGUELET III

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000017897

Policy instance

Insurance contract or identification number	0000017897
Number of Individuals Covered	96
Insurance policy start date	2017-01-01
Insurance policy end date	2017-02-28
Total amount of commissions paid to insurance broker	USD $176
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER,HOSPITAL,ICU,CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $1,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61
Insurance broker organization code?	3
Insurance broker name	BRADY WEISENBERGER

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

Policy contract number

GVTL0471F

Policy instance

Insurance contract or identification number	GVTL0471F
Number of Individuals Covered	116
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,860
Total amount of fees paid to insurance company	USD $1,620
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $32,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,860
Insurance broker organization code?	3
Amount paid for insurance broker fees	1620
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	BENEUSA LLC

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

Policy contract number

GUPR0471F

Policy instance

Insurance contract or identification number	GUPR0471F
Number of Individuals Covered	97
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,071
Total amount of fees paid to insurance company	USD $1,626
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,071
Insurance broker organization code?	3
Amount paid for insurance broker fees	1626
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	BENEUSA LLC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1007358

Policy instance

Insurance contract or identification number	1007358
Number of Individuals Covered	14
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $256
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $3,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $227
Insurance broker organization code?	3
Insurance broker name	LORI TOROK

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

Policy contract number

50790-1723

Policy instance

Insurance contract or identification number	50790-1723
Number of Individuals Covered	158
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $764
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $764
Insurance broker organization code?	3
Insurance broker name	YOURPEOPLE INC/ZENEFITS FTW INS SVC

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

148888

Policy instance

Insurance contract or identification number	148888
Number of Individuals Covered	238
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,630
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,023,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,630
Insurance broker organization code?	3
Insurance broker name	YOURPEOPLE INC, PARKER ROUSE CONRAD

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

Policy contract number

GUC0471F

Policy instance

Insurance contract or identification number	GUC0471F
Number of Individuals Covered	94
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,989
Total amount of fees paid to insurance company	USD $1,541
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,989
Insurance broker organization code?	3
Amount paid for insurance broker fees	1541
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	BENEUSA LLC

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

E1172

Policy instance

Insurance contract or identification number	E1172
Number of Individuals Covered	77
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,719
Total amount of fees paid to insurance company	USD $742
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER,HOSPITAL,ICU,CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $46,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,841
Amount paid for insurance broker fees	270
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3
Insurance broker name	TRACY L HOSTLER

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

0000491084

Policy instance

Insurance contract or identification number	0000491084
Number of Individuals Covered	250
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,060
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,060
Insurance broker organization code?	3
Insurance broker name	YOURPEOPLE INC/ZENEFITS FTW INS SVC

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

Policy contract number

GUPR0471F

Policy instance

Insurance contract or identification number	GUPR0471F
Number of Individuals Covered	106
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,282
Total amount of fees paid to insurance company	USD $1,709
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,932
Insurance broker organization code?	3
Amount paid for insurance broker fees	1709
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	PARKER R CONRAD

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

Policy contract number

GVTL0471F

Policy instance

Insurance contract or identification number	GVTL0471F
Number of Individuals Covered	130
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,758
Total amount of fees paid to insurance company	USD $1,727
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $34,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,178
Insurance broker organization code?	3
Amount paid for insurance broker fees	1727
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	PARKER R CONRAD

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

Policy contract number

50790-1723

Policy instance

Insurance contract or identification number	50790-1723
Number of Individuals Covered	104
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $634
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $477
Insurance broker organization code?	3
Insurance broker name	YOURPEOPLE INC/ZENEFITS FTW INS SVC

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

E1172

Policy instance

Insurance contract or identification number	E1172
Number of Individuals Covered	97
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $12,778
Total amount of fees paid to insurance company	USD $888
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER,HOSPITAL,ICU,CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $47,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,473
Amount paid for insurance broker fees	330
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3
Insurance broker name	PATRICIA ANN HAJOSTEK

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

100735801

Policy instance

Insurance contract or identification number	100735801
Number of Individuals Covered	14
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $267
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $3,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $267
Insurance broker organization code?	3
Insurance broker name	NORIDIAN INSURANCE SERVICES INC

DELTA DENTAL OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55034 )

Policy contract number

0000491084

Policy instance

Insurance contract or identification number	0000491084
Number of Individuals Covered	222
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,139
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,285
Insurance broker organization code?	3
Insurance broker name	YOURPEOPLE INC/ZENEFITS FTW INS SVC

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

148888

Policy instance

Insurance contract or identification number	148888
Number of Individuals Covered	208
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,850
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $834,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,537
Insurance broker organization code?	3
Insurance broker name	YOURPEOPLE INC/ZENEFITS FTW INS SVC

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

Policy contract number

GUC0471F

Policy instance

Insurance contract or identification number	GUC0471F
Number of Individuals Covered	106
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,328
Total amount of fees paid to insurance company	USD $1,674
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,805
Insurance broker organization code?	3
Amount paid for insurance broker fees	1674
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	KENNETH J LONGTIN

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

139147

Policy instance

Insurance contract or identification number	139147
Number of Individuals Covered	180
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $717,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

889895

Policy instance

Insurance contract or identification number	889895
Number of Individuals Covered	212
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

139148

Policy instance

Insurance contract or identification number	139148
Number of Individuals Covered	20
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

139149

Policy instance

Insurance contract or identification number	139149
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $693
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	693
Additional information about fees paid to insurance broker	BROKER INCENTIVE PROGRAM
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC -KENNETH LONGTIN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

100735801

Policy instance

Insurance contract or identification number	100735801
Number of Individuals Covered	17
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $354
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $6,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $354
Insurance broker organization code?	3
Insurance broker name	NORIDIAN INSURANCE SERVICES INC

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

100735801

Policy instance

Insurance contract or identification number	100735801
Number of Individuals Covered	1
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $28
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146
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
Insurance broker organization code?	3
Insurance broker name	NORIDIAN INSURANCE SERVICES INC

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

Policy contract number

GVTL0471F

Policy instance

Insurance contract or identification number	GVTL0471F
Number of Individuals Covered	118
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,100
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $37,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,550
Insurance broker organization code?	3
Insurance broker name	KENNETH J LONGTIN

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

Policy contract number

GUPR0471F

Policy instance

Insurance contract or identification number	GUPR0471F
Number of Individuals Covered	93
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,794
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,397
Insurance broker organization code?	3
Insurance broker name	KENNETH J LONGTIN

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

Policy contract number

GUC0471F

Policy instance

Insurance contract or identification number	GUC0471F
Number of Individuals Covered	91
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,596
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,298
Insurance broker organization code?	3
Insurance broker name	KENNETH J LONGTIN

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

E1172

Policy instance

Insurance contract or identification number	E1172
Number of Individuals Covered	131
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $13,383
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER,HOSPITAL,ICU,CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $43,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,938
Insurance broker organization code?	3
Insurance broker name	TERRY E ANDERSON

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

Policy contract number

50790-1723

Policy instance

Insurance contract or identification number	50790-1723
Number of Individuals Covered	93
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $549
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $549
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC -KENNETH LONGTIN

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

Policy contract number

50790-1723

Policy instance

Insurance contract or identification number	50790-1723
Number of Individuals Covered	100
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $669
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $669
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC -KENNETH LONGTIN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1007358

Policy instance

Insurance contract or identification number	1007358
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $136
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $136
Insurance broker organization code?	3
Insurance broker name	NORIDIAN INSURANCE SERVICES INC

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

139149

Policy instance

Insurance contract or identification number	139149
Number of Individuals Covered	6
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $362
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $362
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC -KENNETH LONGTIN

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

Policy contract number

GUPR0471F

Policy instance

Insurance contract or identification number	GUPR0471F
Number of Individuals Covered	109
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,648
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,824
Insurance broker organization code?	3
Insurance broker name	KENNETH J LONGTIN

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

139148

Policy instance

Insurance contract or identification number	139148
Number of Individuals Covered	19
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,027
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,027
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC -KENNETH LONGTIN

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

Policy contract number

GUC0471F

Policy instance

Insurance contract or identification number	GUC0471F
Number of Individuals Covered	102
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,204
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,602
Insurance broker organization code?	3
Insurance broker name	KENNETH J LONGTIN

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

889895

Policy instance

Insurance contract or identification number	889895
Number of Individuals Covered	262
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,304
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,152
Insurance broker organization code?	3
Insurance broker name	RICK ASCHE

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

144316

Policy instance

Insurance contract or identification number	144316
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $106
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $106
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC -KENNETH LONGTIN

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

Policy contract number

GVTL0471F

Policy instance

Insurance contract or identification number	GVTL0471F
Number of Individuals Covered	123
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,822
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $42,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,911
Insurance broker organization code?	3
Insurance broker name	KENNETH J LONGTIN

MEDICA (National Association of Insurance Commissioners NAIC id number: 1259 )

Policy contract number

139147

Policy instance

Insurance contract or identification number	139147
Number of Individuals Covered	158
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,089
Total amount of fees paid to insurance company	USD $1,530
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $688,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,089
Amount paid for insurance broker fees	1530
Additional information about fees paid to insurance broker	CONTINGENCY FEES
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC -KENNETH LONGTIN

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

1007358

Policy instance

Insurance contract or identification number	1007358
Number of Individuals Covered	17
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $776
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $6,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $776
Insurance broker organization code?	3
Insurance broker name	NORIDIAN INSURANCE SERVICES INC

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

889895

Policy instance

Insurance contract or identification number	889895
Number of Individuals Covered	185
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,888
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 12459 )

Policy contract number

144316

Policy instance

Insurance contract or identification number	144316
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $75
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 12459 )

Policy contract number

139147

Policy instance

Insurance contract or identification number	139147
Number of Individuals Covered	167
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,748
Total amount of fees paid to insurance company	USD $1,244
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $620,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 12459 )

Policy contract number

139148

Policy instance

Insurance contract or identification number	139148
Number of Individuals Covered	23
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,012
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 12459 )

Policy contract number

139149

Policy instance

Insurance contract or identification number	139149
Number of Individuals Covered	8
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $428
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

100735801

Policy instance

Insurance contract or identification number	100735801
Number of Individuals Covered	23
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $373
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $5,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICA (National Association of Insurance Commissioners NAIC id number: 12459 )

Policy contract number

144316

Policy instance

Insurance contract or identification number	144316
Number of Individuals Covered	4
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $168
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $168
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC

MEDICA (National Association of Insurance Commissioners NAIC id number: 12459 )

Policy contract number

139147

Policy instance

Insurance contract or identification number	139147
Number of Individuals Covered	154
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $7,622
Total amount of fees paid to insurance company	USD $2,460
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $545,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,622
Amount paid for insurance broker fees	2460
Additional information about fees paid to insurance broker	CONTINGENCY FEE
Insurance broker organization code?	3
Insurance broker name	LONGTIN AGENCY INC

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

889895

Policy instance

Insurance contract or identification number	889895
Number of Individuals Covered	185
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,768
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $884
Insurance broker organization code?	3
Insurance broker name	RICK ASCHE

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Company Name:	RYDELL AUTO CENTER INC
Employer identification number (EIN):	450236743
NAIC Classification:	441110
NAIC Description:	New Car Dealers