401k Plan data: EMPIRE STATE REALTY TRUST plan

EMPIRE STATE REALTY TRUST 401k Plan overview

Plan Name	EMPIRE STATE REALTY TRUST
Plan identification number	501

EMPIRE STATE REALTY TRUST Benefits

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

401k Sponsoring company profile

EMPIRE STATE REALTY OP, L.P. has sponsored the creation of one or more 401k plans.

Company Name: EMPIRE STATE REALTY OP, L.P.

Employer identification number (EIN): 454685158

NAIC Classification: 531310

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPIRE STATE REALTY TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01 JAMES STORCK 2024-01-23
501 2021-07-01 JAMES STORCK 2023-01-23 JAMES STORCK 2023-01-23
501 2020-07-01 JAMES STORCK 2022-01-26
501 2019-07-01 JAMES STORCK 2021-01-20
501 2019-07-01 JAMES STORCK 2021-03-18
501 2019-07-01 JAMES STORCK 2021-01-20
501 2019-07-01 JAMES STORCK 2021-01-20
501 2019-07-01 JAMES STORCK 2021-01-20
501 2018-07-01 DIANA PAULINO 2020-01-23
501 2018-07-01 JAMES STORCK 2021-03-18
501 2017-07-01
501 2017-07-01 JAMES STORCK 2021-03-18
501 2016-07-01
501 2016-07-01 JAMES STORCK 2021-03-18
501 2015-07-01 CYNTHIA YODICE
501 2014-07-01 CYNTHIA YODICE
501 2013-11-01 CYNTHIA YODICE CYNTHIA YODICE 2016-02-22

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-07-01	JAMES STORCK	2024-01-23
501	2021-07-01	JAMES STORCK	2023-01-23	JAMES STORCK	2023-01-23
501	2020-07-01	JAMES STORCK	2022-01-26
501	2019-07-01	JAMES STORCK	2021-01-20
501	2019-07-01	JAMES STORCK	2021-03-18
501	2019-07-01	JAMES STORCK	2021-01-20
501	2019-07-01	JAMES STORCK	2021-01-20
501	2019-07-01	JAMES STORCK	2021-01-20
501	2018-07-01	DIANA PAULINO	2020-01-23
501	2018-07-01	JAMES STORCK	2021-03-18
501	2017-07-01
501	2017-07-01	JAMES STORCK	2021-03-18
501	2016-07-01
501	2016-07-01	JAMES STORCK	2021-03-18
501	2015-07-01	CYNTHIA YODICE
501	2014-07-01	CYNTHIA YODICE
501	2013-11-01	CYNTHIA YODICE		CYNTHIA YODICE	2016-02-22

Plan Statistics for EMPIRE STATE REALTY TRUST

401k plan membership statisitcs for EMPIRE STATE REALTY TRUST

Measure Date Value
2022: EMPIRE STATE REALTY TRUST 2022 401k membership
Total participants, beginning-of-year 2022-07-01 240
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 217
Number of retired or separated participants receiving benefits 2022-07-01 12
Number of other retired or separated participants entitled to future benefits 2022-07-01 0
Total of all active and inactive participants 2022-07-01 229
2021: EMPIRE STATE REALTY TRUST 2021 401k membership
Total participants, beginning-of-year 2021-07-01 198
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 210
Number of retired or separated participants receiving benefits 2021-07-01 3
Number of other retired or separated participants entitled to future benefits 2021-07-01 27
Total of all active and inactive participants 2021-07-01 240
2020: EMPIRE STATE REALTY TRUST 2020 401k membership
Total participants, beginning-of-year 2020-07-01 235
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 198
Number of retired or separated participants receiving benefits 2020-07-01 10
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 208
2019: EMPIRE STATE REALTY TRUST 2019 401k membership
Total participants, beginning-of-year 2019-07-01 229
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 231
Number of retired or separated participants receiving benefits 2019-07-01 0
Number of other retired or separated participants entitled to future benefits 2019-07-01 0
Total of all active and inactive participants 2019-07-01 231
2018: EMPIRE STATE REALTY TRUST 2018 401k membership
Total participants, beginning-of-year 2018-07-01 234
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 229
Number of retired or separated participants receiving benefits 2018-07-01 0
Number of other retired or separated participants entitled to future benefits 2018-07-01 0
Total of all active and inactive participants 2018-07-01 229
Number of employers contributing to the scheme 2018-07-01 0
2017: EMPIRE STATE REALTY TRUST 2017 401k membership
Total participants, beginning-of-year 2017-07-01 2,017
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 234
Number of retired or separated participants receiving benefits 2017-07-01 0
Number of other retired or separated participants entitled to future benefits 2017-07-01 0
Total of all active and inactive participants 2017-07-01 234
2016: EMPIRE STATE REALTY TRUST 2016 401k membership
Total participants, beginning-of-year 2016-07-01 212
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 207
Number of retired or separated participants receiving benefits 2016-07-01 0
Number of other retired or separated participants entitled to future benefits 2016-07-01 0
Total of all active and inactive participants 2016-07-01 207
2015: EMPIRE STATE REALTY TRUST 2015 401k membership
Total participants, beginning-of-year 2015-07-01 237
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 219
Number of retired or separated participants receiving benefits 2015-07-01 0
Number of other retired or separated participants entitled to future benefits 2015-07-01 0
Total of all active and inactive participants 2015-07-01 219
2014: EMPIRE STATE REALTY TRUST 2014 401k membership
Total participants, beginning-of-year 2014-07-01 201
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 201
Total of all active and inactive participants 2014-07-01 201
Total participants 2014-07-01 201
2013: EMPIRE STATE REALTY TRUST 2013 401k membership
Total participants, beginning-of-year 2013-11-01 191
Total number of active participants reported on line 7a of the Form 5500 2013-11-01 191
Total of all active and inactive participants 2013-11-01 191
Total participants 2013-11-01 191

Measure	Date	Value
2022: EMPIRE STATE REALTY TRUST 2022 401k membership
Total participants, beginning-of-year	2022-07-01	240
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	217
Number of retired or separated participants receiving benefits	2022-07-01	12
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	229
2021: EMPIRE STATE REALTY TRUST 2021 401k membership
Total participants, beginning-of-year	2021-07-01	198
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	210
Number of retired or separated participants receiving benefits	2021-07-01	3
Number of other retired or separated participants entitled to future benefits	2021-07-01	27
Total of all active and inactive participants	2021-07-01	240
2020: EMPIRE STATE REALTY TRUST 2020 401k membership
Total participants, beginning-of-year	2020-07-01	235
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	198
Number of retired or separated participants receiving benefits	2020-07-01	10
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	208
2019: EMPIRE STATE REALTY TRUST 2019 401k membership
Total participants, beginning-of-year	2019-07-01	229
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	231
Number of retired or separated participants receiving benefits	2019-07-01	0
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	231
2018: EMPIRE STATE REALTY TRUST 2018 401k membership
Total participants, beginning-of-year	2018-07-01	234
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	229
Number of retired or separated participants receiving benefits	2018-07-01	0
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	229
Number of employers contributing to the scheme	2018-07-01	0
2017: EMPIRE STATE REALTY TRUST 2017 401k membership
Total participants, beginning-of-year	2017-07-01	2,017
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	234
Number of retired or separated participants receiving benefits	2017-07-01	0
Number of other retired or separated participants entitled to future benefits	2017-07-01	0
Total of all active and inactive participants	2017-07-01	234
2016: EMPIRE STATE REALTY TRUST 2016 401k membership
Total participants, beginning-of-year	2016-07-01	212
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	207
Number of retired or separated participants receiving benefits	2016-07-01	0
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	207
2015: EMPIRE STATE REALTY TRUST 2015 401k membership
Total participants, beginning-of-year	2015-07-01	237
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	219
Number of retired or separated participants receiving benefits	2015-07-01	0
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	219
2014: EMPIRE STATE REALTY TRUST 2014 401k membership
Total participants, beginning-of-year	2014-07-01	201
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	201
Total of all active and inactive participants	2014-07-01	201
Total participants	2014-07-01	201
2013: EMPIRE STATE REALTY TRUST 2013 401k membership
Total participants, beginning-of-year	2013-11-01	191
Total number of active participants reported on line 7a of the Form 5500	2013-11-01	191
Total of all active and inactive participants	2013-11-01	191
Total participants	2013-11-01	191

Form 5500 Responses for EMPIRE STATE REALTY TRUST

2022: EMPIRE STATE REALTY TRUST 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: EMPIRE STATE REALTY TRUST 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: EMPIRE STATE REALTY TRUST 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: EMPIRE STATE REALTY TRUST 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Submission has been amended	No
2019-07-01	This submission is the final filing	No
2019-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-07-01	Plan is a collectively bargained plan	No
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: EMPIRE STATE REALTY TRUST 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Submission has been amended	Yes
2018-07-01	This submission is the final filing	No
2018-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-07-01	Plan is a collectively bargained plan	No
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: EMPIRE STATE REALTY TRUST 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Submission has been amended	Yes
2017-07-01	This submission is the final filing	No
2017-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-07-01	Plan is a collectively bargained plan	No
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: EMPIRE STATE REALTY TRUST 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Submission has been amended	No
2016-07-01	This submission is the final filing	No
2016-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-07-01	Plan is a collectively bargained plan	No
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: EMPIRE STATE REALTY TRUST 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Submission has been amended	No
2015-07-01	This submission is the final filing	No
2015-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-07-01	Plan is a collectively bargained plan	No
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: EMPIRE STATE REALTY TRUST 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	First time form 5500 has been submitted	Yes
2014-07-01	Submission has been amended	No
2014-07-01	This submission is the final filing	No
2014-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-07-01	Plan is a collectively bargained plan	No
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: EMPIRE STATE REALTY TRUST 2013 form 5500 responses
2013-11-01	Type of plan entity	Single employer plan
2013-11-01	Submission has been amended	No
2013-11-01	This submission is the final filing	No
2013-11-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2013-11-01	Plan is a collectively bargained plan	No
2013-11-01	Plan funding arrangement – Insurance	Yes
2013-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

641595

Policy instance

Insurance contract or identification number	641595
Number of Individuals Covered	217
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,809
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $120,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1809
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

269932

Policy instance

Insurance contract or identification number	269932
Number of Individuals Covered	417
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $123
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,167,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $123
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY473

Policy instance

Insurance contract or identification number	NY473
Number of Individuals Covered	18
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $1,116
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $422
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY540

Policy instance

Insurance contract or identification number	NY540
Number of Individuals Covered	28
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $3,152
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,099
Insurance broker organization code?	3

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

Policy contract number

FK429

Policy instance

Insurance contract or identification number	FK429
Number of Individuals Covered	14
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $1,627
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $619
Insurance broker organization code?	3

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

Policy contract number

FK429

Policy instance

Insurance contract or identification number	FK429
Number of Individuals Covered	15
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,484
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $15,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $576
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY540

Policy instance

Insurance contract or identification number	NY540
Number of Individuals Covered	25
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $3,425
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $29,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,189
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY473

Policy instance

Insurance contract or identification number	NY473
Number of Individuals Covered	10
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,032
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $382
Insurance broker organization code?	3

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

Policy contract number

269932

Policy instance

Insurance contract or identification number	269932
Number of Individuals Covered	402
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $10,779
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,324,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,673
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	198
Insurance policy start date	2021-07-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $296
Total amount of fees paid to insurance company	USD $477
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $296
Amount paid for insurance broker fees	206
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

641595

Policy instance

Insurance contract or identification number	641595
Number of Individuals Covered	197
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,741
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $69,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1741
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY473

Policy instance

Insurance contract or identification number	NY473
Number of Individuals Covered	9
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $482
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $232
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	198
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $10,930
Total amount of fees paid to insurance company	USD $9,417
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $137,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,186
Amount paid for insurance broker fees	2551
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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

Policy contract number

0269932

Policy instance

Insurance contract or identification number	0269932
Number of Individuals Covered	409
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $108,355
Total amount of fees paid to insurance company	USD $5,550
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,149,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67,315
Insurance broker organization code?	3
Amount paid for insurance broker fees	5550
Additional information about fees paid to insurance broker	BONUS

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY540

Policy instance

Insurance contract or identification number	NY540
Number of Individuals Covered	27
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $4,966
Total amount of fees paid to insurance company	USD $546
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,862
Amount paid for insurance broker fees	338
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

FK429

Policy instance

Insurance contract or identification number	FK429
Number of Individuals Covered	15
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,941
Total amount of fees paid to insurance company	USD $137
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $492
Insurance broker organization code?	3
Amount paid for insurance broker fees	117
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

918310

Policy instance

Insurance contract or identification number	918310
Number of Individuals Covered	413
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $8,143
Total amount of fees paid to insurance company	USD $12,097
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $298,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,143
Insurance broker organization code?	3
Amount paid for insurance broker fees	12097
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

918310

Policy instance

Insurance contract or identification number	918310
Number of Individuals Covered	413
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $8,143
Total amount of fees paid to insurance company	USD $12,097
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $298,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,143
Insurance broker organization code?	3
Amount paid for insurance broker fees	12097
Additional information about fees paid to insurance broker	BONUS

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

ES16325

Policy instance

Insurance contract or identification number	ES16325
Number of Individuals Covered	430
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $104,174
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,997,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104,174
Insurance broker organization code?	3

COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	250
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
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY473

Policy instance

Insurance contract or identification number	NY473
Number of Individuals Covered	8
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $685
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $360
Insurance broker organization code?	3

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

ES16325

Policy instance

Insurance contract or identification number	ES16325
Number of Individuals Covered	430
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $104,174
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,997,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104,174
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	231
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $10,430
Total amount of fees paid to insurance company	USD $8,106
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $127,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,430
Amount paid for insurance broker fees	1730
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY473

Policy instance

Insurance contract or identification number	NY473
Number of Individuals Covered	8
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $685
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $360
Insurance broker organization code?	3

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

Policy contract number

FK429

Policy instance

Insurance contract or identification number	FK429
Number of Individuals Covered	15
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $2,638
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $20,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,131
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY540

Policy instance

Insurance contract or identification number	NY540
Number of Individuals Covered	36
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $10,344
Total amount of fees paid to insurance company	USD $70
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $47,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,199
Insurance broker organization code?	3
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	FEES

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	231
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $10,430
Total amount of fees paid to insurance company	USD $8,106
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $127,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,430
Amount paid for insurance broker fees	1730
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

ES16325

Policy instance

Insurance contract or identification number	ES16325
Number of Individuals Covered	430
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $104,174
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,997,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $104,174
Insurance broker organization code?	3

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

Policy contract number

918310

Policy instance

Insurance contract or identification number	918310
Number of Individuals Covered	413
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $8,143
Total amount of fees paid to insurance company	USD $12,097
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $298,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,143
Insurance broker organization code?	3
Amount paid for insurance broker fees	12097
Additional information about fees paid to insurance broker	BONUS

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY540

Policy instance

Insurance contract or identification number	NY540
Number of Individuals Covered	36
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $10,344
Total amount of fees paid to insurance company	USD $70
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $47,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,199
Insurance broker organization code?	3
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	FEES

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	229
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $10,556
Total amount of fees paid to insurance company	USD $6,398
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $127,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,556
Insurance broker organization code?	3
Amount paid for insurance broker fees	6398
Additional information about fees paid to insurance broker	SALES AND SERVICE

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	213
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $140,476
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,765,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140,476
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY540

Policy instance

Insurance contract or identification number	NY540
Number of Individuals Covered	39
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $6,105
Total amount of fees paid to insurance company	USD $141
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $42,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,959
Amount paid for insurance broker fees	88
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

FK429

Policy instance

Insurance contract or identification number	FK429
Number of Individuals Covered	15
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $1,973
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $18,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $597
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	229
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $10,556
Total amount of fees paid to insurance company	USD $6,398
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $127,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,556
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SALES AND SERVICE

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	213
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $140,476
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,765,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140,476
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY473

Policy instance

Insurance contract or identification number	NY473
Number of Individuals Covered	9
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $809
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $274
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	231
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $126,109
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,385,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $126,109
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MARSH AND MCLENNAN AGENCY

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	234
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $10,914
Total amount of fees paid to insurance company	USD $6,761
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $135,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $10,914
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker name	BENEFITMALL

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	234
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $10,914
Total amount of fees paid to insurance company	USD $6,761
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $135,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,914
Insurance broker organization code?	3
Amount paid for insurance broker fees	6761
Additional information about fees paid to insurance broker	OVERRIDE

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

Policy contract number

FK429

Policy instance

Insurance contract or identification number	FK429
Number of Individuals Covered	16
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $3,318
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $950
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	231
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $126,109
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,385,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $126,109
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY540

Policy instance

Insurance contract or identification number	NY540
Number of Individuals Covered	47
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $6,843
Total amount of fees paid to insurance company	USD $433
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $53,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,717
Amount paid for insurance broker fees	62
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY473

Policy instance

Insurance contract or identification number	NY473
Number of Individuals Covered	9
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $591
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $229
Insurance broker organization code?	3

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

Policy contract number

FK429

Policy instance

Insurance contract or identification number	FK429
Number of Individuals Covered	16
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $5,442
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,766
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,155
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY473

Policy instance

Insurance contract or identification number	NY473
Number of Individuals Covered	9
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $765
Total amount of fees paid to insurance company	USD $50
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $260
Amount paid for insurance broker fees	7
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

NY540

Policy instance

Insurance contract or identification number	NY540
Number of Individuals Covered	45
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $9,531
Total amount of fees paid to insurance company	USD $205
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER, HOSPITAL
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $53,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,580
Amount paid for insurance broker fees	29
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600666

Policy instance

Insurance contract or identification number	SGN600666
Number of Individuals Covered	231
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $10,943
Total amount of fees paid to insurance company	USD $10,174
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $119,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,943
Amount paid for insurance broker fees	4549
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	219
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $118,774
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,825,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $118,774
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	199
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $114,626
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,717,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $95,911
Insurance broker organization code?	3
Insurance broker name	MARSH AND MCLENNAN AGENCY

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

Policy contract number

501347

Policy instance

Insurance contract or identification number	501347
Number of Individuals Covered	219
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $12,891
Total amount of fees paid to insurance company	USD $4,206
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $192,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,891
Amount paid for insurance broker fees	4206
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	CORPORATE CONSULTING SERVICES

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	201
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $119,211
Total amount of fees paid to insurance company	USD $59,611
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	59611
Commission paid to Insurance Broker	USD $119,211
Insurance broker organization code?	3
Insurance broker name	CORPORATE CONSULTING SERVICES

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

Policy contract number

000D6417

Policy instance

Insurance contract or identification number	000D6417
Number of Individuals Covered	237
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $17,056
Total amount of fees paid to insurance company	USD $9,019
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $366,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,705,682
Amount paid for insurance broker fees	919
Insurance broker name	CORPORATE CONSULTING SERVICES

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	172
Insurance policy start date	2013-11-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $17,170
Total amount of fees paid to insurance company	USD $12,041
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $404,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12041
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Commission paid to Insurance Broker	USD $17,170
Insurance broker organization code?	3
Insurance broker name	CORPORATE CONSULTING SERVICES

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYK700058

Policy instance

Insurance contract or identification number	NYK700058
Number of Individuals Covered	192
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,560
Total amount of fees paid to insurance company	USD $4,196
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $61,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4196
Additional information about fees paid to insurance broker	SALES & SERVICE
Commission paid to Insurance Broker	USD $1,548
Insurance broker name	CORPORATE CONSULTING SERVICES

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGE600186

Policy instance

Insurance contract or identification number	SGE600186
Number of Individuals Covered	192
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $4,399
Total amount of fees paid to insurance company	USD $3,415
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $46,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3415
Additional information about fees paid to insurance broker	SALES & SERVICE
Commission paid to Insurance Broker	USD $1,865
Insurance broker name	CORPORATE CONSULTING SERVICES

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3336075

Policy instance

Insurance contract or identification number	3336075
Number of Individuals Covered	192
Insurance policy start date	2014-01-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $52,152
Total amount of fees paid to insurance company	USD $26,604
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,228,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SGN600418

Policy instance

Insurance contract or identification number	SGN600418
Number of Individuals Covered	192
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,188
Total amount of fees paid to insurance company	USD $2,062
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $24,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2264
Additional information about fees paid to insurance broker	SALES & SERVICE
Commission paid to Insurance Broker	USD $1,130
Insurance broker name	CORPORATE CONSULTING SERVICES

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

SYK600137

Policy instance

Insurance contract or identification number	SYK600137
Number of Individuals Covered	192
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $282
Total amount of fees paid to insurance company	USD $201
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	201
Additional information about fees paid to insurance broker	SALES & SERVICE
Commission paid to Insurance Broker	USD $179
Insurance broker name	CORPORATE CONSULTING SERVICES

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Company Name:	EMPIRE STATE REALTY OP, L.P.
Employer identification number (EIN):	454685158
NAIC Classification:	531310