401k Plan data: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN plan

BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 401k Plan overview

Plan Name	BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN
Plan identification number	502

BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

BOTH INC. DBA GOLDEN CORRAL has sponsored the creation of one or more 401k plans.

Company Name: BOTH INC. DBA GOLDEN CORRAL

Employer identification number (EIN): 541633868

NAIC Classification: 722514
NAIC Description: Cafeterias, Grill Buffets, and Buffets

Additional information about BOTH INC. DBA GOLDEN CORRAL

Jurisdiction of Incorporation: Virginia Secretary of State

Incorporation Date: 1991-07-01

Company Identification Number: 0377824

Legal Registered Office Address: 1453 KEMPSVILLE RD SUITE 107

VIRGINIA BEACH
United States of America (USA)
23464

More information about BOTH INC. DBA GOLDEN CORRAL

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2022-01-01
502 2021-01-01
502 2020-01-01
502 2019-01-01
502 2018-01-01
502 2017-01-01 GARY W. CARTER GARY W.CARTER 2018-09-28
502 2016-01-01 GARY W. CARTER GARY W.CARTER 2017-10-06
502 2015-01-01 GARY W. CARTER GARY W.CARTER 2016-10-15
502 2014-01-01 GARY W. CARTER GARY W.CARTER 2015-10-14

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
502	2022-01-01
502	2021-01-01
502	2020-01-01
502	2019-01-01
502	2018-01-01
502	2017-01-01	GARY W. CARTER	GARY W.CARTER	2018-09-28
502	2016-01-01	GARY W. CARTER	GARY W.CARTER	2017-10-06
502	2015-01-01	GARY W. CARTER	GARY W.CARTER	2016-10-15
502	2014-01-01	GARY W. CARTER	GARY W.CARTER	2015-10-14

Plan Statistics for BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN

401k plan membership statisitcs for BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN

Measure Date Value
2022: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 81
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 71
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 71
2021: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 31
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 81
Number of retired or separated participants receiving benefits 2021-01-01 0
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 81
2020: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 31
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 31
2019: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 116
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 2019-01-01 116
2018: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 118
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 2018-01-01 118
2017: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 123
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 2017-01-01 123
2016: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 124
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 116
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 2016-01-01 116
2015: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 117
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 124
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 2015-01-01 124
2014: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 117
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 2014-01-01 117

Measure	Date	Value
2022: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	81
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	71
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	71
2021: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	31
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	81
Number of retired or separated participants receiving benefits	2021-01-01	0
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	81
2020: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	31
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	31
2019: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	116
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	116
2018: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	118
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	118
2017: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	123
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	123
2016: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	124
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	116
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	116
2015: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	117
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	124
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	124
2014: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	117
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	117

Form 5500 Responses for BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN

2022: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA 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
2021: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA 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
2020: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA 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
2019: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA 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
2018: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA 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
2017: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA 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
2016: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA 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
2015: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA 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
2014: BOTH, INC. DBA GOLDEN CORRAL CAFETERIA PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
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

Insurance Providers Used on plan

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	71
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,722
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,722
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	4
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12
Other welfare benefits provided	VOLUNTARY SPOUSE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $91
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
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

0A0M5FM005

Policy instance

Insurance contract or identification number	0A0M5FM005
Number of Individuals Covered	47
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,097
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $253,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,097
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )

Policy contract number

0A0M5FM001

Policy instance

Insurance contract or identification number	0A0M5FM001
Number of Individuals Covered	56
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,703
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $382,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,703
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	71
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $296
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $296
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	21
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,703
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,703
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	21
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,622
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,622
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

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

Policy contract number

820796-000,001

Policy instance

Insurance contract or identification number	820796-000,001
Number of Individuals Covered	66
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,290
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,677
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
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	11
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $905
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
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 $905
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	5
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $127
Other welfare benefits provided	VOLUNTARY SPOUSE LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $127
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	3
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $17
Other welfare benefits provided	VOLUNTARY CHILD LIFE
Welfare Benefit Premiums Paid to Carrier	USD $128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	9
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $88
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $88
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	26
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,990
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,990
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	81
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,812
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,812
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )

Policy contract number

0A0M5FM001

Policy instance

Insurance contract or identification number	0A0M5FM001
Number of Individuals Covered	57
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,389
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $301,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,389
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

0A0M5FM005

Policy instance

Insurance contract or identification number	0A0M5FM005
Number of Individuals Covered	38
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,511
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $225,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,511
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	81
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $372
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $372
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	25
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,140
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,140
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

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

Policy contract number

820796-000,001

Policy instance

Insurance contract or identification number	820796-000,001
Number of Individuals Covered	94
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,334
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,334
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	14
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $956
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $5,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $956
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	6
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $135
Other welfare benefits provided	VOLUNTARY SPOUSE LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $135
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	6
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $20
Other welfare benefits provided	VOLUNTARY CHILD LIFE
Welfare Benefit Premiums Paid to Carrier	USD $113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	12
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $94
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $94
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	5
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9
Other welfare benefits provided	VOLUNTARY SPOUSE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $52
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	10
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $746
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $746
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	31
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $1,144
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,144
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	31
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $239
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $239
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )

Policy contract number

0A0M5FM001

Policy instance

Insurance contract or identification number	0A0M5FM001
Number of Individuals Covered	27
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $6,385
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $226,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,385
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

0A0M5FM005

Policy instance

Insurance contract or identification number	0A0M5FM005
Number of Individuals Covered	18
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $8,495
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $301,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,495
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	9
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $3,374
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,374
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

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

Policy contract number

820796-000,001

Policy instance

Insurance contract or identification number	820796-000,001
Number of Individuals Covered	47
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $1,945
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,945
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $750
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $3,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $750
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $66
Other welfare benefits provided	VOLUNTARY SPOUSE LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $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 $66
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $10
Other welfare benefits provided	VOLUNTARY CHILD LIFE
Welfare Benefit Premiums Paid to Carrier	USD $48
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
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	4
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $82
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $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 $82
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Insurance policy start date	2020-01-01
Insurance policy end date	2020-01-01
Other welfare benefits provided	VOLUNTARY SPOUSE AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	24
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,627
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $11,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,627
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	7
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $14
Other welfare benefits provided	VOLUNTARY SPOUSE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $99
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	8
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $41
Other welfare benefits provided	VOLUNTARY CHILD LIFE
Welfare Benefit Premiums Paid to Carrier	USD $282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

21796000

Policy instance

Insurance contract or identification number	21796000
Number of Individuals Covered	89
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $10,140
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $622,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,140
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )

Policy contract number

0B325904

Policy instance

Insurance contract or identification number	0B325904
Number of Individuals Covered	87
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,016
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $676,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,016
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	116
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,186
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,186
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	116
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $482
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $482
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	32
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,416
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,416
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	36
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,407
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,407
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

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

Policy contract number

820796-000,001

Policy instance

Insurance contract or identification number	820796-000,001
Number of Individuals Covered	206
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,284
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,284
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	8
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $146
Other welfare benefits provided	VOLUNTARY SPOUSE LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $1,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $146
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	24
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $212
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $212
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	9
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $33
Other welfare benefits provided	VOLUNTARY CHILD LIFE
Welfare Benefit Premiums Paid to Carrier	USD $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 $33
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

21796000

Policy instance

Insurance contract or identification number	21796000
Number of Individuals Covered	89
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $12,158
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $592,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,158
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	118
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,725
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,725
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	118
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $347
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $347
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	33
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,055
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,055
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

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

Policy contract number

820796-000,001

Policy instance

Insurance contract or identification number	820796-000,001
Number of Individuals Covered	207
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,862
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,862
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	34
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,667
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,667
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	9
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $115
Other welfare benefits provided	VOLUNTARY SPOUSE LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $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 $115
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	23
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,165
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $9,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,165
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )

Policy contract number

0B325904

Policy instance

Insurance contract or identification number	0B325904
Number of Individuals Covered	120
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $14,260
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $695,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,260
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	7
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $37
Other welfare benefits provided	VOLUNTARY SPOUSE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

AL00006397

Policy instance

Insurance contract or identification number	AL00006397
Number of Individuals Covered	22
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $153
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $153
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010210467

Policy instance

Insurance contract or identification number	000010210467
Number of Individuals Covered	114
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $272
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $272
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010210467

Policy instance

Insurance contract or identification number	000010210467
Number of Individuals Covered	114
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,495
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,495
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )

Policy contract number

0B325904

Policy instance

Insurance contract or identification number	0B325904
Number of Individuals Covered	123
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $15,665
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $638,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,665
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

21796000

Policy instance

Insurance contract or identification number	21796000
Number of Individuals Covered	97
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $15,541
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $633,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,541
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

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

Policy contract number

820796-000,001

Policy instance

Insurance contract or identification number	820796-000,001
Number of Individuals Covered	199
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,817
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,817
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010210469

Policy instance

Insurance contract or identification number	000010210469
Number of Individuals Covered	40
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,567
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,567
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010210468

Policy instance

Insurance contract or identification number	000010210468
Number of Individuals Covered	43
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,845
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,845
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	21
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,417
Other welfare benefits provided	VOLUNTARY LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $9,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,417
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	8
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $123
Other welfare benefits provided	VOLUNTARY SPOUSE LIFE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $817
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
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	10
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $30
Other welfare benefits provided	VOLUNTARY CHILD LIFE
Welfare Benefit Premiums Paid to Carrier	USD $200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	21
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $141
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $141
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	8
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12
Other welfare benefits provided	VOLUNTARY SPOUSE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $83
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
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM601026

Policy instance

Insurance contract or identification number	SGM601026
Number of Individuals Covered	101
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,632
Total amount of fees paid to insurance company	USD $214
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,632
Amount paid for insurance broker fees	214
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK600512

Policy instance

Insurance contract or identification number	SOK600512
Number of Individuals Covered	101
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $541
Total amount of fees paid to insurance company	USD $25
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $541
Amount paid for insurance broker fees	25
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

21796000

Policy instance

Insurance contract or identification number	21796000
Number of Individuals Covered	7
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $11,308
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $456,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,308
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )

Policy contract number

0B325904

Policy instance

Insurance contract or identification number	0B325904
Number of Individuals Covered	117
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,752
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $513,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,752
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM606088

Policy instance

Insurance contract or identification number	SGM606088
Number of Individuals Covered	18
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $505
Other welfare benefits provided	SUPPLEMENTAL LIFE/DEPENDENT LIFE IN
Welfare Benefit Premiums Paid to Carrier	USD $4,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $505
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD600895

Policy instance

Insurance contract or identification number	SGD600895
Number of Individuals Covered	61
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,694
Total amount of fees paid to insurance company	USD $278
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,694
Amount paid for insurance broker fees	278
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

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

Policy contract number

820796-000

Policy instance

Insurance contract or identification number	820796-000
Number of Individuals Covered	213
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,160
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,160
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )

Policy contract number

0B325904

Policy instance

Insurance contract or identification number	0B325904
Number of Individuals Covered	117
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $11,016
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $497,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,016
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM601026

Policy instance

Insurance contract or identification number	SGM601026
Number of Individuals Covered	114
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,714
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,714
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD600894

Policy instance

Insurance contract or identification number	SGD600894
Number of Individuals Covered	114
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,468
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,468
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD600895

Policy instance

Insurance contract or identification number	SGD600895
Number of Individuals Covered	67
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,007
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,007
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK600512

Policy instance

Insurance contract or identification number	SOK600512
Number of Individuals Covered	114
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $541
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $3,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $541
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

21796000

Policy instance

Insurance contract or identification number	21796000
Number of Individuals Covered	92
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,584
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $482,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,584
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

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

Policy contract number

820796-000

Policy instance

Insurance contract or identification number	820796-000
Number of Individuals Covered	108
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,519
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,519
Additional information about fees paid to insurance broker	EVALUATION OF INSURANCE PLANS NEGOTIATION OF INSURANCE PREMIUMS
Insurance broker organization code?	3
Insurance broker name	WILLIS OF VIRGINIA, INC.

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Company Name:	BOTH INC. DBA GOLDEN CORRAL
Employer identification number (EIN):	541633868
NAIC Classification:	722514
NAIC Description:	Cafeterias, Grill Buffets, and Buffets

Jurisdiction of Incorporation:	Virginia Secretary of State
Incorporation Date:	1991-07-01
Company Identification Number:	0377824
Legal Registered Office Address:	1453 KEMPSVILLE RD SUITE 107 VIRGINIA BEACH United States of America (USA) 23464