401k Plan data: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN plan

NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 401k Plan overview

Plan Name	NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN
Plan identification number	507

NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

NORTHWEST PIPE FITTINGS, INC. has sponsored the creation of one or more 401k plans.

Company Name: NORTHWEST PIPE FITTINGS, INC.

Employer identification number (EIN): 460233970

NAIC Classification: 423700

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
507 2022-01-01
507 2021-01-01
507 2020-01-01
507 2019-01-01
507 2018-01-01
507 2017-01-01 RON HAFFNER SCOTT BARBOUR 2018-06-27
507 2016-01-01 RON HAFFNER SCOTT BARBOUR 2017-05-22
507 2015-01-01 RON HAFFNER SCOTT BARBOUR 2016-06-14
507 2014-01-01 RON HAFFNER SCOTT BARBOUR 2015-05-29
507 2013-01-01 RON HAFFNER SCOTT BARBOUR 2014-05-01
507 2012-01-01 RON HAFFNER SCOTT BARBOUR 2013-05-29
507 2011-01-01 RON HAFFNER SCOTT BARBOUR 2012-07-30
507 2010-01-01 RON HAFFNER SCOTT BARBOUR 2011-06-20
507 2009-01-01 RON HAFFNER SCOTT BARBOUR 2010-06-29

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
507	2022-01-01
507	2021-01-01
507	2020-01-01
507	2019-01-01
507	2018-01-01
507	2017-01-01	RON HAFFNER	SCOTT BARBOUR	2018-06-27
507	2016-01-01	RON HAFFNER	SCOTT BARBOUR	2017-05-22
507	2015-01-01	RON HAFFNER	SCOTT BARBOUR	2016-06-14
507	2014-01-01	RON HAFFNER	SCOTT BARBOUR	2015-05-29
507	2013-01-01	RON HAFFNER	SCOTT BARBOUR	2014-05-01
507	2012-01-01	RON HAFFNER	SCOTT BARBOUR	2013-05-29
507	2011-01-01	RON HAFFNER	SCOTT BARBOUR	2012-07-30
507	2010-01-01	RON HAFFNER	SCOTT BARBOUR	2011-06-20
507	2009-01-01	RON HAFFNER	SCOTT BARBOUR	2010-06-29

Plan Statistics for NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN

401k plan membership statisitcs for NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN

Measure Date Value
2022: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 64
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 70
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 70
2021: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 69
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 68
Number of retired or separated participants receiving benefits 2021-01-01 1
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 69
2020: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 66
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 64
Number of retired or separated participants receiving benefits 2020-01-01 1
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 65
2019: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 89
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 89
2018: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 72
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 72
2017: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 78
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 78
2016: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 77
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 81
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 81
2015: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 77
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 77
2014: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 75
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 75
2013: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 63
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 63
2012: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 103
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 68
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 68
2011: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 69
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 69
2010: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 110
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 110
2009: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 112
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 112
Total of all active and inactive participants 2009-01-01 112

Measure	Date	Value
2022: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	64
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	70
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	70
2021: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	69
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	68
Number of retired or separated participants receiving benefits	2021-01-01	1
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	69
2020: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	66
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	64
Number of retired or separated participants receiving benefits	2020-01-01	1
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	65
2019: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	89
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	89
2018: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	72
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	72
2017: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	78
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	78
2016: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	77
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	81
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	81
2015: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	77
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	77
2014: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	75
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	75
2013: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	63
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	63
2012: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	103
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	68
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	68
2011: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	69
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	69
2010: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	110
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	110
2009: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	112
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	112
Total of all active and inactive participants	2009-01-01	112

Form 5500 Responses for NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN

2022: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Mulitple employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Mulitple employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: NORTHWEST PIPE FITTINGS INCORPORATED FLEXIBLE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Mulitple employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9261577519 000

Policy instance

Insurance contract or identification number	9261577519 000
Number of Individuals Covered	364
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,586
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $34,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,896
Insurance broker organization code?	5

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

22NW01C571

Policy instance

Insurance contract or identification number	22NW01C571
Number of Individuals Covered	70
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,475
Welfare Benefit Premiums Paid to Carrier	USD $502,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,475
Insurance broker organization code?	3

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	73
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,561
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,561
Insurance broker organization code?	5

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	168
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,552
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,552
Insurance broker organization code?	3

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

Policy contract number

70763

Policy instance

Insurance contract or identification number	70763
Number of Individuals Covered	72
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,623
Total amount of fees paid to insurance company	USD $211
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,746
Amount paid for insurance broker fees	126
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3

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

Policy contract number

70763

Policy instance

Insurance contract or identification number	70763
Number of Individuals Covered	63
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,657
Total amount of fees paid to insurance company	USD $483
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,551
Amount paid for insurance broker fees	372
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	168
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,430
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,430
Insurance broker organization code?	3

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	59
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,097
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,212
Insurance broker organization code?	5

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

20NW01C028

Policy instance

Insurance contract or identification number	20NW01C028
Number of Individuals Covered	66
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $20,450
Welfare Benefit Premiums Paid to Carrier	USD $471,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,275
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9261577519 000

Policy instance

Insurance contract or identification number	9261577519 000
Number of Individuals Covered	307
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,861
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $26,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,319
Insurance broker organization code?	5

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

Policy contract number

70763

Policy instance

Insurance contract or identification number	70763
Number of Individuals Covered	60
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,834
Total amount of fees paid to insurance company	USD $375
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,953
Amount paid for insurance broker fees	189
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	160
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,508
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,129
Insurance broker organization code?	3

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	44
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,339
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $953
Insurance broker organization code?	5

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

20NW01C028

Policy instance

Insurance contract or identification number	20NW01C028
Number of Individuals Covered	66
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $49,500
Welfare Benefit Premiums Paid to Carrier	USD $428,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,500
Insurance broker organization code?	5

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9261577519 000

Policy instance

Insurance contract or identification number	9261577519 000
Number of Individuals Covered	303
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,570
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $28,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,990
Insurance broker organization code?	5

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

Policy contract number

70763

Policy instance

Insurance contract or identification number	70763
Number of Individuals Covered	56
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,528
Total amount of fees paid to insurance company	USD $443
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,077
Amount paid for insurance broker fees	180
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	162
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,501
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,501
Insurance broker organization code?	3

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	46
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,501
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,019
Insurance broker organization code?	5

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

19NW01A917

Policy instance

Insurance contract or identification number	19NW01A917
Number of Individuals Covered	76
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $54,875
Welfare Benefit Premiums Paid to Carrier	USD $450,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,875
Insurance broker organization code?	5

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9261577519 000

Policy instance

Insurance contract or identification number	9261577519 000
Number of Individuals Covered	307
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,981
Total amount of fees paid to insurance company	USD $10
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,423
Amount paid for insurance broker fees	10
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	5

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

Policy contract number

70763

Policy instance

Insurance contract or identification number	70763
Number of Individuals Covered	55
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,742
Total amount of fees paid to insurance company	USD $172
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,474
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	164
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,489
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,489
Insurance broker organization code?	3

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	49
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,563
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,044
Insurance broker organization code?	5

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

18NW01K625

Policy instance

Insurance contract or identification number	18NW01K625
Number of Individuals Covered	69
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $50,083
Welfare Benefit Premiums Paid to Carrier	USD $418,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,083
Insurance broker organization code?	5

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9261577519 000

Policy instance

Insurance contract or identification number	9261577519 000
Number of Individuals Covered	302
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $6,075
Total amount of fees paid to insurance company	USD $10
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,516
Amount paid for insurance broker fees	10
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	5

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9261577519000

Policy instance

Insurance contract or identification number	9261577519000
Number of Individuals Covered	326
Insurance policy start date	2017-09-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,390
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,194
Insurance broker organization code?	5
Insurance broker name	SUMMIT REINSURANCE SERVICES INC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

17NW01K431

Policy instance

Insurance contract or identification number	17NW01K431
Number of Individuals Covered	79
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $58,765
Welfare Benefit Premiums Paid to Carrier	USD $617,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,765
Insurance broker organization code?	5
Insurance broker name	MERITAIN HEALTH

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1045864

Policy instance

Insurance contract or identification number	1045864
Number of Individuals Covered	141
Insurance policy start date	2017-01-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $2,954
Total amount of fees paid to insurance company	USD $851
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,954
Amount paid for insurance broker fees	851
Insurance broker organization code?	3
Insurance broker name	INSURANCE PARTNERS AGENCY INC

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	56
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,656
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,082
Insurance broker organization code?	5
Insurance broker name	DIRECT BENEFITS

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	177
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,536
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,536
Insurance broker organization code?	3
Insurance broker name	FIRST WESTERN INSURANCE AGENCY

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

Policy contract number

70763

Policy instance

Insurance contract or identification number	70763
Number of Individuals Covered	52
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,814
Total amount of fees paid to insurance company	USD $84
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,145
Amount paid for insurance broker fees	29
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3
Insurance broker name	FRANCES OSTERMEIER

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	190
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,484
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,484
Insurance broker organization code?	3
Insurance broker name	FIRST WESTERN INSURANCE AGENCY

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	54
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,012
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $874
Insurance broker name	DIRECT BENEFITS

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1045864

Policy instance

Insurance contract or identification number	1045864
Number of Individuals Covered	140
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,083
Total amount of fees paid to insurance company	USD $1,243
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,083
Amount paid for insurance broker fees	448
Insurance broker organization code?	3
Insurance broker name	NFP INSURANCE SERVICES INC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

15NW01K056

Policy instance

Insurance contract or identification number	15NW01K056
Number of Individuals Covered	71
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of fees paid to insurance company	USD $55,314
Welfare Benefit Premiums Paid to Carrier	USD $404,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	55314
Insurance broker organization code?	5
Insurance broker name	MERITAIN HEALTH

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

14NW010074

Policy instance

Insurance contract or identification number	14NW010074
Number of Individuals Covered	75
Insurance policy start date	2014-03-01
Insurance policy end date	2014-12-31
Total amount of fees paid to insurance company	USD $42,455
Welfare Benefit Premiums Paid to Carrier	USD $278,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	42455
Insurance broker organization code?	5
Insurance broker name	MERITAIN HEALTH

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

Policy contract number

56049+

Policy instance

Insurance contract or identification number	56049+
Number of Individuals Covered	128
Insurance policy start date	2014-01-01
Insurance policy end date	2014-02-28
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	44
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,875
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $764
Insurance broker name	DIRECT BENEFITS

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	180
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,390
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,390
Insurance broker organization code?	3
Insurance broker name	FIRST WESTERN INSURANCE AGENCY

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

Policy contract number

000LG7742200

Policy instance

Insurance contract or identification number	000LG7742200
Insurance policy start date	2014-01-01
Insurance policy end date	2014-07-31
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1045864

Policy instance

Insurance contract or identification number	1045864
Number of Individuals Covered	142
Insurance policy start date	2014-08-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,357
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,357
Insurance broker organization code?	3
Insurance broker name	INSURANCE PARTNERS AGENCY INC

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

Policy contract number

7742200

Policy instance

Insurance contract or identification number	7742200
Number of Individuals Covered	69
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,290
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $15,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,290
Insurance broker name	FIRST WESTERN INSURANCE AGENCY INC

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

Policy contract number

56049+

Policy instance

Insurance contract or identification number	56049+
Number of Individuals Covered	130
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	169
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,105
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,105
Insurance broker name	FIRST WESTERN INSURANCE AGENCY

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	45
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,750
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $713
Insurance broker name	DIRECT BENEFITS

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

Policy contract number

56049+56253

Policy instance

Insurance contract or identification number	56049+56253
Number of Individuals Covered	146
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2135

Policy instance

Insurance contract or identification number	2135
Number of Individuals Covered	177
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,110
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,110
Insurance broker name	FIRST WESTERN INSURANCE AGENCY

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	47
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,898
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $773
Insurance broker name	DIRECT BENEFITS

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

Policy contract number

7742200

Policy instance

Insurance contract or identification number	7742200
Number of Individuals Covered	71
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,282
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $16,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,282
Insurance broker name	NISI

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	43
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,664
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

56049

Policy instance

Insurance contract or identification number	56049
Number of Individuals Covered	147
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	169
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,081
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

7742200

Policy instance

Insurance contract or identification number	7742200
Number of Individuals Covered	76
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,215
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $15,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

50790-1139

Policy instance

Insurance contract or identification number	50790-1139
Number of Individuals Covered	39
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,536
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $626
Insurance broker organization code?	3
Insurance broker name	DIRECT BENEFITS

DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )

Policy contract number

2136

Policy instance

Insurance contract or identification number	2136
Number of Individuals Covered	163
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,073
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,073
Insurance broker organization code?	3
Insurance broker name	FIRST WESTERN AGENCY, LLC

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

Policy contract number

56049

Policy instance

Insurance contract or identification number	56049
Number of Individuals Covered	132
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

7742200

Policy instance

Insurance contract or identification number	7742200
Number of Individuals Covered	73
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,267
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $16,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,267
Insurance broker organization code?	3
Insurance broker name	NISI

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Company Name:	NORTHWEST PIPE FITTINGS, INC.
Employer identification number (EIN):	460233970
NAIC Classification:	423700