401k Plan data: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN plan

MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 401k Plan overview

Plan Name	MILLER INSULATION CO., INC, GROUP BENEFIT PLAN
Plan identification number	501

MILLER INSULATION CO., INC, GROUP 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)

401k Sponsoring company profile

MILLER INSULATION CO INC GROUP BENEFIT has sponsored the creation of one or more 401k plans.

Company Name: MILLER INSULATION CO INC GROUP BENEFIT

Employer identification number (EIN): 450376527

NAIC Classification: 238900

Additional information about MILLER INSULATION CO INC GROUP BENEFIT

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 1994-03-02

Company Identification Number: 0009911206

Legal Registered Office Address: 3520 E CENTURY AVE

BISMARCK
United States of America (USA)
58503

More information about MILLER INSULATION CO INC GROUP BENEFIT

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MILLER INSULATION CO., INC, GROUP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 COREY HAGER 2023-09-25 COREY HAGER 2023-09-25
501 2021-01-01 COREY HAGER 2022-09-26 COREY HAGER 2022-09-26
501 2020-01-01 COREY HAGER COREY HAGER
501 2019-01-01 COREY HAGER 2020-08-03 COREY HAGER 2020-08-03
501 2018-01-01 COREY HAGER 2019-10-11 COREY HAGER 2019-10-11
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01 RICK L THOMPSON RICK L THOMPSON 2015-09-29
501 2013-01-01 RICK L THOMPSON RICK L THOMPSON 2014-10-10
501 2012-01-01 RICK L THOMPSON RICK L THOMPSON 2013-10-15
501 2011-01-01 RICK L THOMPSON RICK L THOMPSON 2012-09-27
501 2010-01-01 RICK L THOMPSON RICK L THOMPSON 2011-10-11
501 2009-01-01 RICK L THOMPSON RICK L THOMPSON 2010-10-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	COREY HAGER	2023-09-25	COREY HAGER	2023-09-25
501	2021-01-01	COREY HAGER	2022-09-26	COREY HAGER	2022-09-26
501	2020-01-01	COREY HAGER		COREY HAGER
501	2019-01-01	COREY HAGER	2020-08-03	COREY HAGER	2020-08-03
501	2018-01-01	COREY HAGER	2019-10-11	COREY HAGER	2019-10-11
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01	RICK L THOMPSON		RICK L THOMPSON	2015-09-29
501	2013-01-01	RICK L THOMPSON		RICK L THOMPSON	2014-10-10
501	2012-01-01	RICK L THOMPSON		RICK L THOMPSON	2013-10-15
501	2011-01-01	RICK L THOMPSON		RICK L THOMPSON	2012-09-27
501	2010-01-01	RICK L THOMPSON		RICK L THOMPSON	2011-10-11
501	2009-01-01	RICK L THOMPSON		RICK L THOMPSON	2010-10-13

Plan Statistics for MILLER INSULATION CO., INC, GROUP BENEFIT PLAN

401k plan membership statisitcs for MILLER INSULATION CO., INC, GROUP BENEFIT PLAN

Measure Date Value
2022: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 432
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 430
Total of all active and inactive participants 2022-01-01 430
2021: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 476
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 432
Total of all active and inactive participants 2021-01-01 432
2020: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 587
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 476
Total of all active and inactive participants 2020-01-01 476
2019: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 585
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 587
Total of all active and inactive participants 2019-01-01 587
2018: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 291
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 585
Total of all active and inactive participants 2018-01-01 585
2017: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 273
Total of all active and inactive participants 2017-01-01 273
2016: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 328
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 273
Total of all active and inactive participants 2016-01-01 273
2015: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 356
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 328
Total of all active and inactive participants 2015-01-01 328
2014: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 300
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 356
Total of all active and inactive participants 2014-01-01 356
2013: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 210
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 300
Total of all active and inactive participants 2013-01-01 300
Number of employers contributing to the scheme 2013-01-01 3
2012: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 210
Total of all active and inactive participants 2012-01-01 0
Total participants 2012-01-01 0
2011: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 181
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 210
Total of all active and inactive participants 2011-01-01 210
Total participants 2011-01-01 210
Number of employers contributing to the scheme 2011-01-01 5
2010: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 171
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 181
Total of all active and inactive participants 2010-01-01 181
Total participants 2010-01-01 181
Number of employers contributing to the scheme 2010-01-01 5
2009: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 170
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 171
Total of all active and inactive participants 2009-01-01 171
Total participants 2009-01-01 171

Measure	Date	Value
2022: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	432
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	430
Total of all active and inactive participants	2022-01-01	430
2021: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	476
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	432
Total of all active and inactive participants	2021-01-01	432
2020: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	587
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	476
Total of all active and inactive participants	2020-01-01	476
2019: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	585
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	587
Total of all active and inactive participants	2019-01-01	587
2018: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	291
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	585
Total of all active and inactive participants	2018-01-01	585
2017: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	273
Total of all active and inactive participants	2017-01-01	273
2016: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	328
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	273
Total of all active and inactive participants	2016-01-01	273
2015: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	356
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	328
Total of all active and inactive participants	2015-01-01	328
2014: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	300
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	356
Total of all active and inactive participants	2014-01-01	356
2013: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	210
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	300
Total of all active and inactive participants	2013-01-01	300
Number of employers contributing to the scheme	2013-01-01	3
2012: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	210
Total of all active and inactive participants	2012-01-01	0
Total participants	2012-01-01	0
2011: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	181
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	210
Total of all active and inactive participants	2011-01-01	210
Total participants	2011-01-01	210
Number of employers contributing to the scheme	2011-01-01	5
2010: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	171
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	181
Total of all active and inactive participants	2010-01-01	181
Total participants	2010-01-01	181
Number of employers contributing to the scheme	2010-01-01	5
2009: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	171
Total of all active and inactive participants	2009-01-01	171
Total participants	2009-01-01	171

Form 5500 Responses for MILLER INSULATION CO., INC, GROUP BENEFIT PLAN

2022: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2021: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2020: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2019: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2018: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2017: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2016: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2015: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2014: MILLER INSULATION CO., INC, GROUP 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 benefit arrangement – Insurance	Yes
2013: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Multi-employer plan
2013-01-01	Plan is a collectively bargained plan	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Multi-employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Multi-employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Multi-employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: MILLER INSULATION CO., INC, GROUP BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Multi-employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

PPF25

Policy instance

Insurance contract or identification number	PPF25
Number of Individuals Covered	7
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,106
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,461
Insurance broker organization code?	4

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

168078

Policy instance

Insurance contract or identification number	168078
Number of Individuals Covered	19
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,345
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $11,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,345
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

168078

Policy instance

Insurance contract or identification number	168078
Number of Individuals Covered	223
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,814
Total amount of fees paid to insurance company	USD $0
Life 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 $7,777
Insurance broker organization code?	3

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

Policy contract number

10308401001

Policy instance

Insurance contract or identification number	10308401001
Number of Individuals Covered	400
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,144
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,144
Insurance broker organization code?	3

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

Policy contract number

252506

Policy instance

Insurance contract or identification number	252506
Number of Individuals Covered	415
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 $1,846,676
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

10308401001

Policy instance

Insurance contract or identification number	10308401001
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $15
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15
Insurance broker organization code?	3

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

Policy contract number

100410

Policy instance

Insurance contract or identification number	100410
Number of Individuals Covered	430
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

252506

Policy instance

Insurance contract or identification number	252506
Number of Individuals Covered	426
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 $1,881,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

100410

Policy instance

Insurance contract or identification number	100410
Number of Individuals Covered	468
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
Dental Insurance Welfare Benefit	Yes
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

10308401001

Policy instance

Insurance contract or identification number	10308401001
Number of Individuals Covered	432
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,531
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,531
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

168078

Policy instance

Insurance contract or identification number	168078
Number of Individuals Covered	219
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,194
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,112
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

168078

Policy instance

Insurance contract or identification number	168078
Number of Individuals Covered	11
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,465
Total amount of fees paid to insurance company	USD $0
Temporary Disability 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 $1,332
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

168078

Policy instance

Insurance contract or identification number	168078
Number of Individuals Covered	18
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,231
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $12,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,231
Insurance broker organization code?	3

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

Policy contract number

252506

Policy instance

Insurance contract or identification number	252506
Number of Individuals Covered	466
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 $2,051,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

252506

Policy instance

Insurance contract or identification number	252506
Number of Individuals Covered	476
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $151,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

252506

Policy instance

Insurance contract or identification number	252506
Number of Individuals Covered	452
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	1
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	56
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,425
Total amount of fees paid to insurance company	USD $337
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,333
Amount paid for insurance broker fees	52
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	53
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $29,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	16
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAM
Welfare Benefit Premiums Paid to Carrier	USD $4,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	10
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	248
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $9,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	248
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $7,734
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,734
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION
Insurance broker organization code?	3

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	233
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $31,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	13
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	18
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAM
Welfare Benefit Premiums Paid to Carrier	USD $4,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	57
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $32,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $7,711
Total amount of fees paid to insurance company	USD $0
Life 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 $7,711
Insurance broker organization code?	3

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	64
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $12,242
Total amount of fees paid to insurance company	USD $802
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,173
Amount paid for insurance broker fees	422
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

25206

Policy instance

Insurance contract or identification number	25206
Number of Individuals Covered	539
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	1
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

25206

Policy instance

Insurance contract or identification number	25206
Number of Individuals Covered	587
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $183,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

25206

Policy instance

Insurance contract or identification number	25206
Number of Individuals Covered	597
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 $2,273,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	233
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $8,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	573
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	61
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $33,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	226
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $7,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	226
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $28,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	226
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAM
Welfare Benefit Premiums Paid to Carrier	USD $4,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	61
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $7,458
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,458
Insurance broker organization code?	3

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	64
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $18,004
Total amount of fees paid to insurance company	USD $606
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,555
Amount paid for insurance broker fees	267
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	3
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	542
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	585
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $178,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	60
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $6,846
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,846
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION
Insurance broker organization code?	3
Insurance broker name	DARYL BRAUN

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	70
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,631
Total amount of fees paid to insurance company	USD $375
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $84,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,084
Amount paid for insurance broker fees	77
Additional information about fees paid to insurance broker	SALES AND SERVICE COMPENSATION
Insurance broker organization code?	3
Insurance broker name	DAWN D SHEUE

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	3
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	488
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	60
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $31,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAM
Welfare Benefit Premiums Paid to Carrier	USD $3,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	224
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	224
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $25,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	224
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $7,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	523
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
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $159,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	515
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	270
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $27,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	270
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAM
Welfare Benefit Premiums Paid to Carrier	USD $3,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	61
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $25,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	61
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $6,510
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,510
Insurance broker organization code?	3
Insurance broker name	DARYL BRAUN

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	74
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $23,631
Total amount of fees paid to insurance company	USD $2,269
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,874
Amount paid for insurance broker fees	985
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICES
Insurance broker organization code?	3
Insurance broker name	JULIE SMITH

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	5
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
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 $2,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	533
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	587
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $181,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	587
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	270
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BASIC AD&D INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $8,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	520
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	260
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	579
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $310,405
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	310405
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEESADMINISTRATIVE SERVICES
Insurance broker organization code?	3
Insurance broker name

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	571
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
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 $145,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	6
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	79
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $14,773
Total amount of fees paid to insurance company	USD $751
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,234
Amount paid for insurance broker fees	307
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICES
Insurance broker organization code?	3
Insurance broker name	MICHAEL C WALKER

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	54
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $5,796
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,796
Insurance broker organization code?	3
Insurance broker name	DARYL BRAUN

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	54
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
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
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $21,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
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
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAM
Welfare Benefit Premiums Paid to Carrier	USD $3,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	260
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
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
Other welfare benefits provided	BASIC AD&D INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $7,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
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
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	260
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
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
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $25,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LINCOLN MUTUAL LIFE & CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65641 )

Policy contract number

000LG2226700

Policy instance

Insurance contract or identification number	000LG2226700
Number of Individuals Covered	1
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
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
Other welfare benefits provided	VOLUNTARY DEP LIFE CHILD
Welfare Benefit Premiums Paid to Carrier	USD $142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	196
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
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
Other welfare benefits provided	BASIC LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $17,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	196
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
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
Other welfare benefits provided	VOLUNTARY DEP LIFE SPOUSE/FAM
Welfare Benefit Premiums Paid to Carrier	USD $3,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	51
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
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
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $18,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	51
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $4,576
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,576
Insurance broker organization code?	3
Insurance broker name	DARYL BRAUN

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	55
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $15,314
Total amount of fees paid to insurance company	USD $111
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,773
Amount paid for insurance broker fees	83
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICES
Insurance broker organization code?	3
Insurance broker name	LANCE E SULLIVAN

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	6
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
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE VISION SERVICE CORPORATION OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 47053 )

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	456
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE DENTAL SERVICE CORPORATION OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 47054 )

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	507
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 $137,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	498
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 $176,145
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	176145
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICES
Insurance broker organization code?	3
Insurance broker name

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	196
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
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
Other welfare benefits provided	BASIC AD&D INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $5,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LINCOLN MUTUAL LIFE & CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65641 )

Policy contract number

000LG2226700

Policy instance

Insurance contract or identification number	000LG2226700
Number of Individuals Covered	1
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	178
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $3,963
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,633
Commission paid to Insurance Broker	USD $3,963
Insurance broker organization code?	3
Insurance broker name	DARYL BRAUN

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	47
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,043
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,296
Commission paid to Insurance Broker	USD $2,481
Insurance broker organization code?	3
Insurance broker name	DANIEL D LINDBERG

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	432
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of fees paid to insurance company	USD $114,300
Health Insurance Welfare Benefit	Yes
Amount paid for insurance broker fees	114300
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICES
Insurance broker organization code?	3
Insurance broker name	BLUE CROSS BLUE SHIELD OF NORTH DAK

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	6
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,487

THE VISION SERVICE CORPORATION OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 47053 )

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	410
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,455

THE DENTAL SERVICE CORPORATION OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 47054 )

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	449
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $121,988

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	415
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of fees paid to insurance company	USD $96,736
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE DENTAL SERVICE CORPORATION OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 47054 )

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	418
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $108,239

THE VISION SERVICE CORPORATION OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 47053 )

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	408
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,237

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	143
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $3,618
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,180

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	6
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,487

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	43
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,937
Total amount of fees paid to insurance company	USD $353
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	394
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of fees paid to insurance company	USD $86,532
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	86532
Insurance broker organization code?	3
Insurance broker name	BLUE CROSS BLUE SHIELD OF ND

THE DENTAL SERVICE CORPORATION OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 47054 )

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	404
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $107,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE VISION SERVICE CORPORATION OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 47053 )

Policy contract number

69013

Policy instance

Insurance contract or identification number	69013
Number of Individuals Covered	385
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7110794

Policy instance

Insurance contract or identification number	E7110794
Number of Individuals Covered	5
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $74
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $74
Insurance broker organization code?	3
Insurance broker name	BOB STEIN

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

Policy contract number

0DUC8

Policy instance

Insurance contract or identification number	0DUC8
Number of Individuals Covered	43
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $8,287
Total amount of fees paid to insurance company	USD $434
Health Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,402
Amount paid for insurance broker fees	183
Insurance broker organization code?	3
Insurance broker name	JOSEPH GRAY

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

54128

Policy instance

Insurance contract or identification number	54128
Number of Individuals Covered	151
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $2,886
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,886
Insurance broker organization code?	3
Insurance broker name	DARYL BRAUN

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Company Name:	MILLER INSULATION CO INC GROUP BENEFIT
Employer identification number (EIN):	450376527
NAIC Classification:	238900

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	1994-03-02
Company Identification Number:	0009911206
Legal Registered Office Address:	3520 E CENTURY AVE BISMARCK United States of America (USA) 58503