401k Plan data: JACOBI LEWIS COMPANY 401K PS PLAN plan

JACOBI LEWIS COMPANY 401K PS PLAN 401k Plan overview

Plan Name	JACOBI LEWIS COMPANY 401K PS PLAN
Plan identification number	001

JACOBI LEWIS COMPANY 401K PS PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Participant-directed brokerage accounts provided as an investment option under the plan.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

JACOBI LEWIS COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name: JACOBI LEWIS COMPANY, INC.

Employer identification number (EIN): 560495038

NAIC Classification: 532210
NAIC Description: Consumer Electronics and Appliances Rental

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JACOBI LEWIS COMPANY 401K PS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01 E WILSON HORTON, JR 2023-05-03
001 2021-01-01 E WILSON HORTON, JR 2022-07-06
001 2020-01-01 WILSON HORTON JR 2021-03-31
001 2019-01-01 WILSON HORTON JR 2020-05-12
001 2018-01-01 E WILSON HORTON JR. 2019-06-12
001 2017-01-01 E WILSON HORTON JR. 2018-06-15
001 2016-01-01 E WILSON HORTON, JR. 2017-06-22
001 2015-01-01 E. WILSON HORTON, JR 2016-06-16 GREG LEWIS 2016-06-16
001 2014-01-01 E WILSON HORTON JR
001 2013-01-01 WILSON HORTON
001 2012-01-01 WILSON HORTON WILSON HORTON 2013-07-03
001 2011-01-01 GREG LEWIS
001 2010-01-01 E. WILSON HORTON, JR.
001 2009-01-01 E. WILSON HORTON, JR.

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01	E WILSON HORTON, JR	2023-05-03
001	2021-01-01	E WILSON HORTON, JR	2022-07-06
001	2020-01-01	WILSON HORTON JR	2021-03-31
001	2019-01-01	WILSON HORTON JR	2020-05-12
001	2018-01-01	E WILSON HORTON JR.	2019-06-12
001	2017-01-01	E WILSON HORTON JR.	2018-06-15
001	2016-01-01	E WILSON HORTON, JR.	2017-06-22
001	2015-01-01	E. WILSON HORTON, JR	2016-06-16	GREG LEWIS	2016-06-16
001	2014-01-01	E WILSON HORTON JR
001	2013-01-01	WILSON HORTON
001	2012-01-01	WILSON HORTON		WILSON HORTON	2013-07-03
001	2011-01-01	GREG LEWIS
001	2010-01-01	E. WILSON HORTON, JR.
001	2009-01-01	E. WILSON HORTON, JR.

Plan Statistics for JACOBI LEWIS COMPANY 401K PS PLAN

401k plan membership statisitcs for JACOBI LEWIS COMPANY 401K PS PLAN

Measure Date Value
2014: JACOBI LEWIS COMPANY 401K PS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 21
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 21
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 4
Total of all active and inactive participants 2014-01-01 25
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 25
Number of participants with account balances 2014-01-01 24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: JACOBI LEWIS COMPANY 401K PS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 21
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 20
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 3
Total of all active and inactive participants 2013-01-01 23
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 23
Number of participants with account balances 2013-01-01 23
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: JACOBI LEWIS COMPANY 401K PS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 24
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 20
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 3
Total of all active and inactive participants 2012-01-01 23
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 23
Number of participants with account balances 2012-01-01 20
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 3
2011: JACOBI LEWIS COMPANY 401K PS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 28
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 21
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 3
Total of all active and inactive participants 2011-01-01 24
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 24
Number of participants with account balances 2011-01-01 19
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: JACOBI LEWIS COMPANY 401K PS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 28
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 20
Number of retired or separated participants receiving benefits 2010-01-01 3
Number of other retired or separated participants entitled to future benefits 2010-01-01 4
Total of all active and inactive participants 2010-01-01 27
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 27
Number of participants with account balances 2010-01-01 23
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: JACOBI LEWIS COMPANY 401K PS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 29
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 22
Number of retired or separated participants receiving benefits 2009-01-01 2
Number of other retired or separated participants entitled to future benefits 2009-01-01 4
Total of all active and inactive participants 2009-01-01 28
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 28
Number of participants with account balances 2009-01-01 24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2014: JACOBI LEWIS COMPANY 401K PS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	21
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	21
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	4
Total of all active and inactive participants	2014-01-01	25
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	25
Number of participants with account balances	2014-01-01	24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: JACOBI LEWIS COMPANY 401K PS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	21
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	20
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	3
Total of all active and inactive participants	2013-01-01	23
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	23
Number of participants with account balances	2013-01-01	23
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: JACOBI LEWIS COMPANY 401K PS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	24
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	20
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	3
Total of all active and inactive participants	2012-01-01	23
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	23
Number of participants with account balances	2012-01-01	20
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	3
2011: JACOBI LEWIS COMPANY 401K PS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	28
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	21
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	3
Total of all active and inactive participants	2011-01-01	24
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	24
Number of participants with account balances	2011-01-01	19
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: JACOBI LEWIS COMPANY 401K PS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	28
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	20
Number of retired or separated participants receiving benefits	2010-01-01	3
Number of other retired or separated participants entitled to future benefits	2010-01-01	4
Total of all active and inactive participants	2010-01-01	27
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	27
Number of participants with account balances	2010-01-01	23
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: JACOBI LEWIS COMPANY 401K PS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	29
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	22
Number of retired or separated participants receiving benefits	2009-01-01	2
Number of other retired or separated participants entitled to future benefits	2009-01-01	4
Total of all active and inactive participants	2009-01-01	28
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	28
Number of participants with account balances	2009-01-01	24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on JACOBI LEWIS COMPANY 401K PS PLAN

Measure	Date	Value
2014 : JACOBI LEWIS COMPANY 401K PS PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$2
Total income from all sources	2014-12-31	$115,758
Expenses. Total of all expenses incurred	2014-12-31	$7,908
Benefits paid (including direct rollovers)	2014-12-31	$7,660
Total plan assets at end of year	2014-12-31	$1,777,084
Total plan assets at beginning of year	2014-12-31	$1,669,232
Value of fidelity bond covering the plan	2014-12-31	$100,000
Total contributions received or receivable from participants	2014-12-31	$41,359
Expenses. Other expenses not covered elsewhere	2014-12-31	$248
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$59,999
Net income (gross income less expenses)	2014-12-31	$107,850
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$1,777,084
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$1,669,232
Assets. Value of participant loans	2014-12-31	$27,642
Total contributions received or receivable from employer(s)	2014-12-31	$14,400
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2014-12-31	$0
Minimum employer required contribution for this plan year	2014-12-31	$0
Amount contributed by the employer to the plan for this plan year	2014-12-31	$0
2013 : JACOBI LEWIS COMPANY 401K PS PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$237
Total income from all sources	2013-12-31	$229,092
Expenses. Total of all expenses incurred	2013-12-31	$53,479
Benefits paid (including direct rollovers)	2013-12-31	$53,137
Total plan assets at end of year	2013-12-31	$1,669,232
Total plan assets at beginning of year	2013-12-31	$1,493,382
Value of fidelity bond covering the plan	2013-12-31	$100,000
Total contributions received or receivable from participants	2013-12-31	$44,279
Expenses. Other expenses not covered elsewhere	2013-12-31	$342
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$171,205
Net income (gross income less expenses)	2013-12-31	$175,613
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$1,669,232
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$1,493,382
Assets. Value of participant loans	2013-12-31	$35,501
Total contributions received or receivable from employer(s)	2013-12-31	$13,608
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2013-12-31	$0
Minimum employer required contribution for this plan year	2013-12-31	$0
Amount contributed by the employer to the plan for this plan year	2013-12-31	$0
2012 : JACOBI LEWIS COMPANY 401K PS PLAN 2012 401k financial data
Transfers to/from the plan	2012-12-31	$266,616
Total income from all sources	2012-12-31	$229,092
Expenses. Total of all expenses incurred	2012-12-31	$320,916
Benefits paid (including direct rollovers)	2012-12-31	$320,648
Total plan assets at end of year	2012-12-31	$1,493,382
Total plan assets at beginning of year	2012-12-31	$1,318,590
Value of fidelity bond covering the plan	2012-12-31	$100,000
Total contributions received or receivable from participants	2012-12-31	$62,804
Expenses. Other expenses not covered elsewhere	2012-12-31	$268
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$148,879
Net income (gross income less expenses)	2012-12-31	$-91,824
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$1,493,382
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$1,318,590
Assets. Value of participant loans	2012-12-31	$5,399
Total contributions received or receivable from employer(s)	2012-12-31	$17,409
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2012-12-31	$0
Minimum employer required contribution for this plan year	2012-12-31	$0
Amount contributed by the employer to the plan for this plan year	2012-12-31	$0
2011 : JACOBI LEWIS COMPANY 401K PS PLAN 2011 401k financial data
Total income from all sources	2011-12-31	$-79,945
Expenses. Total of all expenses incurred	2011-12-31	$8,295
Benefits paid (including direct rollovers)	2011-12-31	$8,295
Total plan assets at end of year	2011-12-31	$1,318,590
Total plan assets at beginning of year	2011-12-31	$1,406,830
Value of fidelity bond covering the plan	2011-12-31	$100,000
Total contributions received or receivable from participants	2011-12-31	$64,530
Other income received	2011-12-31	$-161,711
Net income (gross income less expenses)	2011-12-31	$-88,240
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$1,318,590
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$1,406,830
Total contributions received or receivable from employer(s)	2011-12-31	$17,236
2010 : JACOBI LEWIS COMPANY 401K PS PLAN 2010 401k financial data
Total income from all sources	2010-12-31	$215,978
Expenses. Total of all expenses incurred	2010-12-31	$44,270
Total plan assets at end of year	2010-12-31	$1,406,830
Total plan assets at beginning of year	2010-12-31	$1,235,122
Value of fidelity bond covering the plan	2010-12-31	$100,000
Total contributions received or receivable from participants	2010-12-31	$52,622
Other income received	2010-12-31	$148,152
Net income (gross income less expenses)	2010-12-31	$171,708
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$1,406,830
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$1,235,122
Total contributions received or receivable from employer(s)	2010-12-31	$15,204
Expenses. Administrative service providers (salaries,fees and commissions)	2010-12-31	$44,270

Form 5500 Responses for JACOBI LEWIS COMPANY 401K PS PLAN

2014: JACOBI LEWIS COMPANY 401K PS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: JACOBI LEWIS COMPANY 401K PS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: JACOBI LEWIS COMPANY 401K PS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: JACOBI LEWIS COMPANY 401K PS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: JACOBI LEWIS COMPANY 401K PS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: JACOBI LEWIS COMPANY 401K PS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-828902

Policy instance

Insurance contract or identification number	GA-828902
Number of Individuals Covered	24
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,303
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,303
Insurance broker organization code?	3
Insurance broker name	EDWARD D JONES & CO L P.

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-828902

Policy instance

Insurance contract or identification number	GA-828902
Number of Individuals Covered	23
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,319
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,319
Insurance broker organization code?	3
Insurance broker name	EDWARD D JONES

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-828902

Policy instance

Insurance contract or identification number	GA-828902
Number of Individuals Covered	20
Insurance policy start date	2012-02-03
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $11,805
Total amount of fees paid to insurance company	USD $890
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,805
Insurance broker organization code?	3
Amount paid for insurance broker fees	890
Additional information about fees paid to insurance broker	SALES/MARKETING
Insurance broker name	EDWARD D JONES & CO

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Company Name:	JACOBI LEWIS COMPANY, INC.
Employer identification number (EIN):	560495038
NAIC Classification:	532210
NAIC Description:	Consumer Electronics and Appliances Rental