MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 401k Plan overview

Plan Name	MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN
Plan identification number	501

MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE 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) Prepaid legal Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

MID-ATLANTIC WOMENS CARE, PLC has sponsored the creation of one or more 401k plans.

Company Name:	MID-ATLANTIC WOMENS CARE, PLC
Employer identification number (EIN):	541820401
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-01-01
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	ROBERT R. STERLING
501	2016-01-01	ROBERT R. STERLING
501	2015-01-01	ROBERT R. STERLING
501	2014-01-01	ROBERT R. STERLING
501	2013-01-01	ROBERT R. STERLING
501	2012-01-01	ROBERT R. STERLING
501	2011-01-01	ROBERT R. STERLING
501	2009-01-01	ROBERT R. STERLING

Plan Statistics for MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN

401k plan membership statisitcs for MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN

Measure	Date	Value
2021: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	448
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	0
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	0
2020: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	456
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	448
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	448
2019: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	424
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	456
Total of all active and inactive participants	2019-01-01	456
2018: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	413
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	458
Total of all active and inactive participants	2018-01-01	458
2017: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	612
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	563
Number of retired or separated participants receiving benefits	2017-01-01	6
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	569
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	569
2016: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	673
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	607
Number of retired or separated participants receiving benefits	2016-01-01	5
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	612
Total participants	2016-01-01	612
2015: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	565
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	665
Number of retired or separated participants receiving benefits	2015-01-01	8
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	673
Total participants	2015-01-01	673
2014: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	515
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	560
Number of retired or separated participants receiving benefits	2014-01-01	5
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	565
Total participants	2014-01-01	565
2013: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	523
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	514
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	1
Total of all active and inactive participants	2013-01-01	515
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	515
2012: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	539
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	519
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	4
Total of all active and inactive participants	2012-01-01	523
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	523
2011: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	477
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	530
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	9
Total of all active and inactive participants	2011-01-01	539
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	539
Number of participants with account balances	2011-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2009: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	479
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	503
Number of retired or separated participants receiving benefits	2009-01-01	1
Number of other retired or separated participants entitled to future benefits	2009-01-01	5
Total of all active and inactive participants	2009-01-01	509
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	509

Form 5500 Responses for MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN

2021: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	Yes
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE 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: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE 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: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: MID-ATLANTIC WOMENS CARE, PLC WELFARE BENEFIT HEALTH INSURANCE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )
Policy contract number	60743
Policy instance	19
Insurance contract or identification number 60743 Number of Individuals Covered 60 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $3,525 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $156,252 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,525 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	MG-142 234310
Policy instance	22
Insurance contract or identification number MG-142 234310 Number of Individuals Covered 3 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $110 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $733 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $110 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553625
Policy instance	21
Insurance contract or identification number E3553625 Number of Individuals Covered 4 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $106 Total amount of fees paid to insurance company USD $1 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $87 Insurance broker organization code? 3 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker BROKER BONUS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3063575
Policy instance	20
Insurance contract or identification number E3063575 Number of Individuals Covered 11 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $372 Total amount of fees paid to insurance company USD $9 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,018 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $244 Insurance broker organization code? 3 Amount paid for insurance broker fees 9 Additional information about fees paid to insurance broker BROKER BONUS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553724
Policy instance	18
Insurance contract or identification number E3553724 Number of Individuals Covered 1 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $69 Total amount of fees paid to insurance company USD $3 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $253 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $38 Insurance broker organization code? 3 Amount paid for insurance broker fees 3 Additional information about fees paid to insurance broker BROKER BONUS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK968217
Policy instance	17
Insurance contract or identification number OK968217 Number of Individuals Covered 6 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $7 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,406 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 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553633
Policy instance	16
Insurance contract or identification number E3553633 Number of Individuals Covered 3 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $38 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $421 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074747
Policy instance	15
Insurance contract or identification number E3074747 Number of Individuals Covered 1 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $44 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $556 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964601
Policy instance	14
Insurance contract or identification number LK 964601 Number of Individuals Covered 6 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $349 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $40,609 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $349 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966748
Policy instance	13
Insurance contract or identification number FLX966748 Number of Individuals Covered 3 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $110 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,837 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $110 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702152
Policy instance	12
Insurance contract or identification number E7702152 Number of Individuals Covered 11 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $2,614 Total amount of fees paid to insurance company USD $90 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,290 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,338 Insurance broker organization code? 3 Amount paid for insurance broker fees 90 Additional information about fees paid to insurance broker BROKER BONUS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7894942
Policy instance	11
Insurance contract or identification number E7894942 Number of Individuals Covered 5 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $540 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,571 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 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702160
Policy instance	10
Insurance contract or identification number E7702160 Number of Individuals Covered 6 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $587 Total amount of fees paid to insurance company USD $22 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,722 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $325 Insurance broker organization code? 3 Amount paid for insurance broker fees 22 Additional information about fees paid to insurance broker BROKER BONUS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966695
Policy instance	23
Insurance contract or identification number FLX966695 Number of Individuals Covered 3 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $188 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,391 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $188 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553658
Policy instance	24
Insurance contract or identification number E3553658 Number of Individuals Covered 1 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $2 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $159 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 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553633
Policy instance	9
Insurance contract or identification number E3553633 Number of Individuals Covered 3 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $37 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $421 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 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3341779
Policy instance	8
Insurance contract or identification number 3341779 Number of Individuals Covered 305 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $4,687 Total amount of fees paid to insurance company USD $-906 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $94,497 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,687 Amount paid for insurance broker fees -906 Additional information about fees paid to insurance broker GENERAL AGENT PAYMENTS Insurance broker organization code? 3
LEGAL RESOURCES (National Association of Insurance Commissioners NAIC id number: 48402 )
Policy contract number	2301*
Policy instance	7
Insurance contract or identification number 2301* Number of Individuals Covered 91 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,276 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3264
Policy instance	6
Insurance contract or identification number 3264 Number of Individuals Covered 171 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $7,839 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $353,298 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,839 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E770636
Policy instance	5
Insurance contract or identification number E770636 Number of Individuals Covered 3 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $85 Total amount of fees paid to insurance company USD $4 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $432 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $39 Insurance broker organization code? 3 Amount paid for insurance broker fees 4 Additional information about fees paid to insurance broker BROKER BONUS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074903
Policy instance	4
Insurance contract or identification number E3074903 Number of Individuals Covered 1 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $23 Total amount of fees paid to insurance company USD $1 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $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 $8 Insurance broker organization code? 3 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker BROKER BONUS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961855
Policy instance	3
Insurance contract or identification number VDT961855 Number of Individuals Covered 3 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $132 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,105 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $132 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	MG-142 2310
Policy instance	2
Insurance contract or identification number MG-142 2310 Number of Individuals Covered 1 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $67 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $446 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30033159
Policy instance	25
Insurance contract or identification number 30033159 Number of Individuals Covered 243 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $443 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $16,115 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $443 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4866372
Policy instance	26
Insurance contract or identification number E4866372 Number of Individuals Covered 1 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $9 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $293 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7 Insurance broker organization code? 3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3213
Policy instance	27
Insurance contract or identification number 3213 Number of Individuals Covered 236 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $14,054 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $640,448 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,054 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702186
Policy instance	1
Insurance contract or identification number E7702186 Number of Individuals Covered 5 Insurance policy start date 2021-01-01 Insurance policy end date 2021-05-31 Total amount of commissions paid to insurance broker USD $112 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,513 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $97 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553633
Policy instance	12
Insurance contract or identification number E3553633 Number of Individuals Covered 3 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $160 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,288 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $133 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553625
Policy instance	11
Insurance contract or identification number E3553625 Number of Individuals Covered 4 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $518 Total amount of fees paid to insurance company USD $24 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,529 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $447 Amount paid for insurance broker fees 12 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553658
Policy instance	10
Insurance contract or identification number E3553658 Number of Individuals Covered 1 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $7 Life Insurance Welfare Benefit Yes 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 $4 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702186
Policy instance	9
Insurance contract or identification number E7702186 Number of Individuals Covered 6 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $519 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,645 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $456 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702160
Policy instance	8
Insurance contract or identification number E7702160 Number of Individuals Covered 8 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,301 Total amount of fees paid to insurance company USD $104 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,438 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $887 Amount paid for insurance broker fees 53 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553724
Policy instance	7
Insurance contract or identification number E3553724 Number of Individuals Covered 1 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $121 Total amount of fees paid to insurance company USD $8 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $516 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $75 Amount paid for insurance broker fees 4 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3063575
Policy instance	6
Insurance contract or identification number E3063575 Number of Individuals Covered 11 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,166 Total amount of fees paid to insurance company USD $77 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,161 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $854 Amount paid for insurance broker fees 36 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7894942
Policy instance	5
Insurance contract or identification number E7894942 Number of Individuals Covered 7 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,061 Total amount of fees paid to insurance company USD $95 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,656 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $628 Amount paid for insurance broker fees 46 Insurance broker organization code? 3
LEGAL RESOURCES (National Association of Insurance Commissioners NAIC id number: 48402 )
Policy contract number
Policy instance	4
Number of Individuals Covered 107 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Other welfare benefits provided LEGAL INSURANCE & ID PROTECTI Welfare Benefit Premiums Paid to Carrier USD $29,763 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30033159
Policy instance	3
Insurance contract or identification number 30033159 Number of Individuals Covered 237 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,540 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $35,198 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,540 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7700636
Policy instance	2
Insurance contract or identification number E7700636 Number of Individuals Covered 2 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $140 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $857 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $72 Insurance broker organization code? 3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3213
Policy instance	1
Insurance contract or identification number 3213 Number of Individuals Covered 254 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $34,156 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,620,705 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,156 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074903
Policy instance	13
Insurance contract or identification number E3074903 Number of Individuals Covered 1 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $46 Total amount of fees paid to insurance company USD $3 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $477 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 Insurance broker organization code? 3 Amount paid for insurance broker fees 1
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074747
Policy instance	14
Insurance contract or identification number E3074747 Number of Individuals Covered 2 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $155 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,529 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $122 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK968217
Policy instance	15
Insurance contract or identification number OK968217 Number of Individuals Covered 236 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $465 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $4,648 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $465 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964601
Policy instance	18
Insurance contract or identification number LK 964601 Number of Individuals Covered 489 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $6,652 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $68,193 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $6,652 Insurance broker organization code? 3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3264
Policy instance	26
Insurance contract or identification number 3264 Number of Individuals Covered 178 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $30,730 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $829,340 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,730 Insurance broker organization code? 3
CIGNA DENTAL HEALTH OF VIRGINIA, INC. (National Association of Insurance Commissioners NAIC id number: 52617 )
Policy contract number	3341779
Policy instance	25
Insurance contract or identification number 3341779 Number of Individuals Covered 67 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $947 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $18,946 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $947 Insurance broker organization code? 3
CIGNA DENTAL HEALTH OF NORTH CAROLINA, INC. (National Association of Insurance Commissioners NAIC id number: 95179 )
Policy contract number	3341779
Policy instance	24
Insurance contract or identification number 3341779 Number of Individuals Covered 2 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $27 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $541 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3341779
Policy instance	23
Insurance contract or identification number 3341779 Number of Individuals Covered 297 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $10,356 Total amount of fees paid to insurance company USD $1,813 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $208,804 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,356 Amount paid for insurance broker fees 1813 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4866372
Policy instance	22
Insurance contract or identification number E4866372 Number of Individuals Covered 1 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $31 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $702 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23 Insurance broker organization code? 3
OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )
Policy contract number	60743
Policy instance	21
Insurance contract or identification number 60743 Number of Individuals Covered 61 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $7,763 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $346,217 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,763 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966748
Policy instance	16
Insurance contract or identification number FLX966748 Number of Individuals Covered 575 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $2,434 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $19,476 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $2,434 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966695
Policy instance	17
Insurance contract or identification number FLX966695 Number of Individuals Covered 236 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $2,419 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $24,508 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $2,419 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553732
Policy instance	27
Insurance contract or identification number E3553732 Number of Individuals Covered 1 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $35 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 $32 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961855
Policy instance	19
Insurance contract or identification number VDT961855 Number of Individuals Covered 167 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $3,314 Other welfare benefits provided VOLUNTARY SHORT TERM DISABILITY Welfare Benefit Premiums Paid to Carrier USD $34,615 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $3,314 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702152
Policy instance	20
Insurance contract or identification number E7702152 Number of Individuals Covered 10 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $4,077 Total amount of fees paid to insurance company USD $339 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,937 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,307 Amount paid for insurance broker fees 188 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK968217
Policy instance	20
Insurance contract or identification number OK968217 Number of Individuals Covered 143 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $715 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $7,148 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $715 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	MG14224310
Policy instance	19
Insurance contract or identification number MG14224310 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 $553 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,399 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $553 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074747
Policy instance	18
Insurance contract or identification number E3074747 Number of Individuals Covered 2 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $368 Total amount of fees paid to insurance company USD $17 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,778 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $303 Insurance broker organization code? 3 Amount paid for insurance broker fees 14
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074903
Policy instance	17
Insurance contract or identification number E3074903 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $19 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $435 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 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553633
Policy instance	16
Insurance contract or identification number E3553633 Number of Individuals Covered 6 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $276 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,562 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $234 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553732
Policy instance	15
Insurance contract or identification number E3553732 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $84 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $845 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $76 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553625
Policy instance	14
Insurance contract or identification number E3553625 Number of Individuals Covered 5 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $409 Total amount of fees paid to insurance company USD $7 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,016 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $361 Insurance broker organization code? 3 Amount paid for insurance broker fees 6
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553658
Policy instance	13
Insurance contract or identification number E3553658 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $28 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966748
Policy instance	21
Insurance contract or identification number FLX966748 Number of Individuals Covered 348 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $4,239 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $33,914 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,239 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966695
Policy instance	22
Insurance contract or identification number FLX966695 Number of Individuals Covered 143 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,771 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $37,713 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,771 Insurance broker organization code? 3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3264
Policy instance	31
Insurance contract or identification number 3264 Number of Individuals Covered 154 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $16,502 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $418,103 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,502 Insurance broker organization code? 3
CIGNA DENTAL HEALTH OF NORTH CAROLINA, INC. (National Association of Insurance Commissioners NAIC id number: 95179 )
Policy contract number	3341779
Policy instance	29
Insurance contract or identification number 3341779 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $17 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $343 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 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3341779
Policy instance	28
Insurance contract or identification number 3341779 Number of Individuals Covered 304 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $10,828 Total amount of fees paid to insurance company USD $1,722 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $218,458 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,828 Amount paid for insurance broker fees 1722 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4866372
Policy instance	27
Insurance contract or identification number E4866372 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $173 Total amount of fees paid to insurance company USD $9 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $702 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $149 Insurance broker organization code? 3 Amount paid for insurance broker fees 7
OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )
Policy contract number	60743
Policy instance	26
Insurance contract or identification number 60743 Number of Individuals Covered 93 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $4,975 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $392,591 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,975 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702152
Policy instance	25
Insurance contract or identification number E7702152 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 $635 Total amount of fees paid to insurance company USD $9 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,174 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $549 Insurance broker organization code? 3 Amount paid for insurance broker fees 7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961855
Policy instance	24
Insurance contract or identification number VDT961855 Number of Individuals Covered 101 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $5,288 Other welfare benefits provided VOLUNTARY SHORT TERM DISABILITY Welfare Benefit Premiums Paid to Carrier USD $52,875 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,288 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964601
Policy instance	23
Insurance contract or identification number LK 964601 Number of Individuals Covered 296 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $11,523 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $115,230 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,523 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553617
Policy instance	12
Insurance contract or identification number E3553617 Number of Individuals Covered 0 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $140 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,271 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $126 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702186
Policy instance	11
Insurance contract or identification number E7702186 Number of Individuals Covered 9 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,532 Total amount of fees paid to insurance company USD $79 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,504 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,310 Insurance broker organization code? 3 Amount paid for insurance broker fees 64
CIGNA DENTAL HEALTH OF VIRGINIA, INC. (National Association of Insurance Commissioners NAIC id number: 52617 )
Policy contract number	3341779
Policy instance	30
Insurance contract or identification number 3341779 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 $1,195 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $23,901 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,195 Insurance broker organization code? 3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3213
Policy instance	1
Insurance contract or identification number 3213 Number of Individuals Covered 350 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $24,884 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,925,476 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,884 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7700636
Policy instance	2
Insurance contract or identification number E7700636 Number of Individuals Covered 2 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $69 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,023 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $44 Insurance broker organization code? 3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3219
Policy instance	3
Insurance contract or identification number 3219 Number of Individuals Covered 41 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $495 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $83,494 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $495 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30033159
Policy instance	4
Insurance contract or identification number 30033159 Number of Individuals Covered 264 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,440 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $31,748 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,440 Insurance broker organization code? 3
LEGAL RESOURCES (National Association of Insurance Commissioners NAIC id number: 48402 )
Policy contract number
Policy instance	5
Number of Individuals Covered 84 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Other welfare benefits provided LEGAL INSURANCE & ID PROTECTI Welfare Benefit Premiums Paid to Carrier USD $25,777 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7894942
Policy instance	6
Insurance contract or identification number E7894942 Number of Individuals Covered 6 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $573 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,907 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $494 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3063575
Policy instance	7
Insurance contract or identification number E3063575 Number of Individuals Covered 13 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,576 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $8,155 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,186 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553724
Policy instance	8
Insurance contract or identification number E3553724 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $39 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $390 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $35 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7701543
Policy instance	9
Insurance contract or identification number E7701543 Number of Individuals Covered 1 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $9 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $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 $7 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702160
Policy instance	10
Insurance contract or identification number E7702160 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 $593 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,942 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $526 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553724
Policy instance	9
Insurance contract or identification number E3553724 Number of Individuals Covered 1 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $36 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $390 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7701543
Policy instance	10
Insurance contract or identification number E7701543 Number of Individuals Covered 1 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $15 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $515 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 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702160
Policy instance	11
Insurance contract or identification number E7702160 Number of Individuals Covered 8 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $438 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,736 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $377 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702186
Policy instance	12
Insurance contract or identification number E7702186 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 $1,055 Total amount of fees paid to insurance company USD $52 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,029 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $892 Insurance broker organization code? 3 Amount paid for insurance broker fees 38
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553617
Policy instance	13
Insurance contract or identification number E3553617 Number of Individuals Covered 1 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $438 Total amount of fees paid to insurance company USD $22 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,790 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $380 Insurance broker organization code? 3 Amount paid for insurance broker fees 16
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553658
Policy instance	14
Insurance contract or identification number E3553658 Number of Individuals Covered 2 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $87 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,205 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $73 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3063575
Policy instance	8
Insurance contract or identification number E3063575 Number of Individuals Covered 13 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $915 Total amount of fees paid to insurance company USD $39 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,393 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $778 Insurance broker organization code? 3 Amount paid for insurance broker fees 29
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7894942
Policy instance	7
Insurance contract or identification number E7894942 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 $668 Total amount of fees paid to insurance company USD $10 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,353 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $533 Insurance broker organization code? 3 Amount paid for insurance broker fees 7
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30033159
Policy instance	5
Insurance contract or identification number 30033159 Number of Individuals Covered 259 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,355 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $30,556 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,355 Insurance broker organization code? 3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3219
Policy instance	4
Insurance contract or identification number 3219 Number of Individuals Covered 39 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $2,114 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $168,420 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,057 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7700636
Policy instance	3
Insurance contract or identification number E7700636 Number of Individuals Covered 2 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $63 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,023 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $40 Insurance broker organization code? 3
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number	7827
Policy instance	2
Insurance contract or identification number 7827 Number of Individuals Covered 645 Insurance policy start date 2018-01-01 Insurance policy end date 2018-05-31 Total amount of commissions paid to insurance broker USD $4,906 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,906 Insurance broker organization code? 3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3213
Policy instance	1
Insurance contract or identification number 3213 Number of Individuals Covered 415 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $13,530 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,621,250 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,765 Insurance broker organization code? 3
LEGAL SERVICES (National Association of Insurance Commissioners NAIC id number: 48402 )
Policy contract number
Policy instance	6
Number of Individuals Covered 98 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Other welfare benefits provided IDENTITY PROTECTION Welfare Benefit Premiums Paid to Carrier USD $34,948 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553625
Policy instance	15
Insurance contract or identification number E3553625 Number of Individuals Covered 4 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $654 Total amount of fees paid to insurance company USD $28 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,041 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $548 Insurance broker organization code? 3 Amount paid for insurance broker fees 21
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553732
Policy instance	16
Insurance contract or identification number E3553732 Number of Individuals Covered 1 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $95 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,296 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $83 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553633
Policy instance	17
Insurance contract or identification number E3553633 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 $241 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,343 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $191 Insurance broker organization code? 3
CIGNA DENTAL HEALTH OF VIRGINIA, INC. (National Association of Insurance Commissioners NAIC id number: 52617 )
Policy contract number	3341779
Policy instance	31
Insurance contract or identification number 3341779 Number of Individuals Covered 84 Insurance policy start date 2018-06-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $786 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $15,707 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $786 Insurance broker organization code? 3
CIGNA DENTAL HEALTH OF NORTH CAROLINA, INC. (National Association of Insurance Commissioners NAIC id number: 95179 )
Policy contract number	3341779
Policy instance	30
Insurance contract or identification number 3341779 Number of Individuals Covered 1 Insurance policy start date 2018-06-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $12 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $241 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 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3341779
Policy instance	29
Insurance contract or identification number 3341779 Number of Individuals Covered 308 Insurance policy start date 2018-06-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $6,034 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $121,756 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,034 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4866372
Policy instance	28
Insurance contract or identification number E4866372 Number of Individuals Covered 1 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $171 Total amount of fees paid to insurance company USD $9 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $531 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $148 Insurance broker organization code? 3 Amount paid for insurance broker fees 7
OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )
Policy contract number	60743
Policy instance	27
Insurance contract or identification number 60743 Number of Individuals Covered 96 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,484 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $450,996 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,242 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702152
Policy instance	26
Insurance contract or identification number E7702152 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 $547 Total amount of fees paid to insurance company USD $1 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,997 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $461 Insurance broker organization code? 3 Amount paid for insurance broker fees 1
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961855
Policy instance	25
Insurance contract or identification number VDT961855 Number of Individuals Covered 111 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,471 Welfare Benefit Premiums Paid to Carrier USD $44,705 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,471 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964601
Policy instance	24
Insurance contract or identification number LK 964601 Number of Individuals Covered 336 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $12,790 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $127,897 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,790 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074903
Policy instance	18
Insurance contract or identification number E3074903 Number of Individuals Covered 1 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $18 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $435 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 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074747
Policy instance	19
Insurance contract or identification number E3074747 Number of Individuals Covered 2 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $339 Total amount of fees paid to insurance company USD $17 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,573 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $273 Insurance broker organization code? 3 Amount paid for insurance broker fees 13
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	MG14224310
Policy instance	20
Insurance contract or identification number MG14224310 Number of Individuals Covered 91 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $10,957 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $73,024 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,957 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK968217
Policy instance	21
Insurance contract or identification number OK968217 Number of Individuals Covered 157 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $426 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $4,262 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $426 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966748
Policy instance	22
Insurance contract or identification number FLX966748 Number of Individuals Covered 336 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,116 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $32,932 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,116 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966695
Policy instance	23
Insurance contract or identification number FLX966695 Number of Individuals Covered 157 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $4,304 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $43,034 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,304 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702160
Policy instance	14
Insurance contract or identification number E7702160 Number of Individuals Covered 9 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $737 Total amount of fees paid to insurance company USD $21 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,136 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $572 Insurance broker organization code? 3 Amount paid for insurance broker fees 5 Insurance broker name BENEFIT DESIGN GROUP INC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702178
Policy instance	13
Insurance contract or identification number E7702178 Number of Individuals Covered 5 Insurance policy start date 2017-01-01 Insurance policy end date 2017-05-31 Total amount of commissions paid to insurance broker USD $68 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,718 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53 Insurance broker organization code? 3 Insurance broker name SUZANNE R BROSEMER
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7701543
Policy instance	12
Insurance contract or identification number E7701543 Number of Individuals Covered 2 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $74 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,055 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $63 Insurance broker organization code? 3 Insurance broker name JOHN E CUMMINGS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553724
Policy instance	11
Insurance contract or identification number E3553724 Number of Individuals Covered 1 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $44 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $444 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $40 Insurance broker organization code? 3 Insurance broker name JOHN E CUMMINGS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3063575
Policy instance	10
Insurance contract or identification number E3063575 Number of Individuals Covered 13 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $948 Total amount of fees paid to insurance company USD $30 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $7,615 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $791 Insurance broker organization code? 3 Amount paid for insurance broker fees 21 Insurance broker name AFFORDABLE BENEFITS LLC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7894942
Policy instance	9
Insurance contract or identification number E7894942 Number of Individuals Covered 7 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,617 Total amount of fees paid to insurance company USD $101 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,706 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,094 Insurance broker organization code? 3 Amount paid for insurance broker fees 24 Insurance broker name AFFORDABLE BENEFITS LLC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553666
Policy instance	8
Insurance contract or identification number E3553666 Number of Individuals Covered 1 Insurance policy start date 2017-01-01 Insurance policy end date 2017-06-30 Total amount of commissions paid to insurance broker USD $57 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $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 $51 Insurance broker organization code? 3 Insurance broker name JOHN E CUMMINGS
LEGAL SERVICES (National Association of Insurance Commissioners NAIC id number: 48402 )
Policy contract number
Policy instance	7
Number of Individuals Covered 110 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Other welfare benefits provided LEGAL Welfare Benefit Premiums Paid to Carrier USD $18,074 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30033159
Policy instance	6
Insurance contract or identification number 30033159 Number of Individuals Covered 248 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,325 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $28,878 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,325 Insurance broker organization code? 3 Insurance broker name BENEFIT DESIGN GROUP INC
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3219
Policy instance	5
Insurance contract or identification number 3219 Number of Individuals Covered 113 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $8,610 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $382,736 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,305 Insurance broker organization code? 3 Insurance broker name THE FRIEDEN AGENCY
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7700636
Policy instance	4
Insurance contract or identification number E7700636 Number of Individuals Covered 2 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $69 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,023 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $45 Insurance broker organization code? 3 Insurance broker name AFFORDABLE BENEFITS LLC
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number	7827
Policy instance	3
Insurance contract or identification number 7827 Number of Individuals Covered 662 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $9,453 Dental Insurance Welfare Benefit Yes Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,453 Insurance broker organization code? 3 Insurance broker name THE FRIEDEN AGENCY
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3207
Policy instance	2
Insurance contract or identification number 3207 Number of Individuals Covered 260 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $26,902 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,206,044 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,451 Insurance broker organization code? 3 Insurance broker name THE FRIEDEN AGNECY
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553732
Policy instance	19
Insurance contract or identification number E3553732 Number of Individuals Covered 2 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $121 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,747 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $103 Insurance broker organization code? 3 Insurance broker name JOHN E CUMMINGS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702186
Policy instance	15
Insurance contract or identification number E7702186 Number of Individuals Covered 7 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $471 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,164 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $391 Insurance broker organization code? 3 Insurance broker name AFFORDABLE BENEFITS LLC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553617
Policy instance	16
Insurance contract or identification number E3553617 Number of Individuals Covered 2 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $552 Total amount of fees paid to insurance company USD $26 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,162 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $460 Insurance broker organization code? 3 Amount paid for insurance broker fees 18 Insurance broker name JOHN E CUMMINGS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553658
Policy instance	17
Insurance contract or identification number E3553658 Number of Individuals Covered 3 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $130 Total amount of fees paid to insurance company USD $3 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,484 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $102 Insurance broker organization code? 3 Amount paid for insurance broker fees 1 Insurance broker name BENEFITS COUNT INC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E4866372
Policy instance	31
Insurance contract or identification number E4866372 Number of Individuals Covered 1 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $7 Welfare Benefit Premiums Paid to Carrier USD $168 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 Insurance broker organization code? 3 Insurance broker name JOHN E CUMMINGS
OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )
Policy contract number	60743
Policy instance	30
Insurance contract or identification number 60743 Number of Individuals Covered 85 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $8,090 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $362,675 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,045 Insurance broker organization code? 3 Insurance broker name THE FRIEDEN AGENCY
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E7702152
Policy instance	29
Insurance contract or identification number E7702152 Number of Individuals Covered 7 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $738 Total amount of fees paid to insurance company USD $14 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,983 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $591 Insurance broker organization code? 3 Amount paid for insurance broker fees 3 Insurance broker name AFFORDABLE BENEFITS LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	VDT961855
Policy instance	28
Insurance contract or identification number VDT961855 Number of Individuals Covered 356 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $4,466 Other welfare benefits provided SHORT TERM DISABILITY Welfare Benefit Premiums Paid to Carrier USD $44,659 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,466 Insurance broker organization code? 3 Insurance broker name TFA BENEFITS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 964601
Policy instance	27
Insurance contract or identification number LK 964601 Number of Individuals Covered 356 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $14,247 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $142,465 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,247 Insurance broker organization code? 3 Insurance broker name THE FRIEDEN AGENCY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966695
Policy instance	26
Insurance contract or identification number FLX966695 Number of Individuals Covered 356 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $4,549 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $45,487 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,549 Insurance broker organization code? 3 Insurance broker name TFA BENEFITS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX966748
Policy instance	25
Insurance contract or identification number FLX966748 Number of Individuals Covered 356 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $3,953 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $31,623 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 Insurance broker organization code? 3 Insurance broker name THE FRIEDEN AGENCY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK968217
Policy instance	24
Insurance contract or identification number OK968217 Number of Individuals Covered 356 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $399 Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $3,987 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $399 Insurance broker organization code? 3 Insurance broker name THE FRIEDEN AGENCY
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	MG14224310
Policy instance	23
Insurance contract or identification number MG14224310 Number of Individuals Covered 160 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $11,319 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $75,460 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,319 Insurance broker organization code? 3 Insurance broker name THE FRIEDEN AGENCY
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074747
Policy instance	22
Insurance contract or identification number E3074747 Number of Individuals Covered 2 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $123 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,917 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $59 Insurance broker organization code? 3 Insurance broker name AFFORDABLE BENEFITS LLC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3074903
Policy instance	21
Insurance contract or identification number E3074903 Number of Individuals Covered 1 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $19 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $435 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 Insurance broker organization code? 3 Insurance broker name JOHN E CUMMINGS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553633
Policy instance	20
Insurance contract or identification number E3553633 Number of Individuals Covered 7 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $446 Total amount of fees paid to insurance company USD $11 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,070 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $335 Insurance broker organization code? 3 Amount paid for insurance broker fees 3 Insurance broker name BENEFITS COUNT INC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3553625
Policy instance	18
Insurance contract or identification number E3553625 Number of Individuals Covered 6 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,129 Total amount of fees paid to insurance company USD $64 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,880 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $853 Insurance broker organization code? 3 Amount paid for insurance broker fees 40 Insurance broker name JOHN E CUMMINGS
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number	3213
Policy instance	1
Insurance contract or identification number 3213 Number of Individuals Covered 168 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $19,270 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $870,815 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,635 Insurance broker organization code? 3 Insurance broker name VEITH & COMPANY