401k Plan data: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN plan

ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	501

ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

ADAMS ELECTRIC COMPANY has sponsored the creation of one or more 401k plans.

Company Name: ADAMS ELECTRIC COMPANY

Employer identification number (EIN): 560693887

NAIC Classification: 423600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-04-01 TOM SONRICKER TOM SONRICKER 2018-12-06
501 2016-04-01 TOM SONRICKER TOM SONRICKER 2017-10-31
501 2015-04-01 TOM SONRICKER TOM SONRICKER 2016-10-31
501 2014-04-01 TOM SONRICKER TOM SONRICKER 2015-07-13
501 2013-04-01 TOM SONRICKER TOM SONRICKER 2015-01-14
501 2012-04-01 TOM SONRICKER TOM SONRICKER 2014-01-15
501 2011-04-01 TOM SONRICKER TOM SONRICKER 2013-01-14
501 2009-04-01 GEORGE MATTHEWS GEORGE MATTHEWS 2010-10-11

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2017-04-01	TOM SONRICKER	TOM SONRICKER	2018-12-06
501	2016-04-01	TOM SONRICKER	TOM SONRICKER	2017-10-31
501	2015-04-01	TOM SONRICKER	TOM SONRICKER	2016-10-31
501	2014-04-01	TOM SONRICKER	TOM SONRICKER	2015-07-13
501	2013-04-01	TOM SONRICKER	TOM SONRICKER	2015-01-14
501	2012-04-01	TOM SONRICKER	TOM SONRICKER	2014-01-15
501	2011-04-01	TOM SONRICKER	TOM SONRICKER	2013-01-14
501	2009-04-01	GEORGE MATTHEWS	GEORGE MATTHEWS	2010-10-11

Plan Statistics for ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2017: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-04-01 181
Total number of active participants reported on line 7a of the Form 5500 2017-04-01 195
Total of all active and inactive participants 2017-04-01 195
2016: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-04-01 181
Total number of active participants reported on line 7a of the Form 5500 2016-04-01 171
Total of all active and inactive participants 2016-04-01 171
2015: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-04-01 222
Total number of active participants reported on line 7a of the Form 5500 2015-04-01 181
Total of all active and inactive participants 2015-04-01 181
2014: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-04-01 138
Total number of active participants reported on line 7a of the Form 5500 2014-04-01 222
Total of all active and inactive participants 2014-04-01 222
2013: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-04-01 137
Total number of active participants reported on line 7a of the Form 5500 2013-04-01 138
Total of all active and inactive participants 2013-04-01 138
2012: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-04-01 220
Total number of active participants reported on line 7a of the Form 5500 2012-04-01 137
Total of all active and inactive participants 2012-04-01 137
2011: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-04-01 169
Total number of active participants reported on line 7a of the Form 5500 2011-04-01 220
Total of all active and inactive participants 2011-04-01 220
2009: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-04-01 209
Total number of active participants reported on line 7a of the Form 5500 2009-04-01 146
Total of all active and inactive participants 2009-04-01 146

Measure	Date	Value
2017: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-04-01	181
Total number of active participants reported on line 7a of the Form 5500	2017-04-01	195
Total of all active and inactive participants	2017-04-01	195
2016: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-04-01	181
Total number of active participants reported on line 7a of the Form 5500	2016-04-01	171
Total of all active and inactive participants	2016-04-01	171
2015: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-04-01	222
Total number of active participants reported on line 7a of the Form 5500	2015-04-01	181
Total of all active and inactive participants	2015-04-01	181
2014: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-04-01	138
Total number of active participants reported on line 7a of the Form 5500	2014-04-01	222
Total of all active and inactive participants	2014-04-01	222
2013: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-04-01	137
Total number of active participants reported on line 7a of the Form 5500	2013-04-01	138
Total of all active and inactive participants	2013-04-01	138
2012: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-04-01	220
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	137
Total of all active and inactive participants	2012-04-01	137
2011: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-04-01	169
Total number of active participants reported on line 7a of the Form 5500	2011-04-01	220
Total of all active and inactive participants	2011-04-01	220
2009: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-04-01	209
Total number of active participants reported on line 7a of the Form 5500	2009-04-01	146
Total of all active and inactive participants	2009-04-01	146

Form 5500 Responses for ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN

2017: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-04-01	Type of plan entity	Single employer plan
2017-04-01	Plan funding arrangement – Insurance	Yes
2017-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-04-01	Plan benefit arrangement – Insurance	Yes
2017-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-04-01	Type of plan entity	Single employer plan
2016-04-01	Plan funding arrangement – Insurance	Yes
2016-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-04-01	Plan benefit arrangement – Insurance	Yes
2016-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-04-01	Type of plan entity	Single employer plan
2015-04-01	Plan funding arrangement – Insurance	Yes
2015-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-04-01	Plan benefit arrangement – Insurance	Yes
2015-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-04-01	Type of plan entity	Single employer plan
2014-04-01	Plan funding arrangement – Insurance	Yes
2014-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-04-01	Plan benefit arrangement – Insurance	Yes
2014-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-04-01	Type of plan entity	Single employer plan
2013-04-01	Plan funding arrangement – Insurance	Yes
2013-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-04-01	Plan benefit arrangement – Insurance	Yes
2013-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-04-01	Type of plan entity	Single employer plan
2012-04-01	Plan funding arrangement – Insurance	Yes
2012-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-04-01	Plan benefit arrangement – Insurance	Yes
2012-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-04-01	Type of plan entity	Single employer plan
2011-04-01	Plan funding arrangement – Insurance	Yes
2011-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-04-01	Plan benefit arrangement – Insurance	Yes
2011-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-04-01	Type of plan entity	Single employer plan
2009-04-01	This submission is the final filing	No
2009-04-01	Plan funding arrangement – Insurance	Yes
2009-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-04-01	Plan benefit arrangement – Insurance	Yes
2009-04-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0AWZQ

Policy instance

Insurance contract or identification number	GUDH0AWZQ
Number of Individuals Covered	60
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $510
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $510
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0AWZQ

Policy instance

Insurance contract or identification number	GUDE0AWZQ
Number of Individuals Covered	58
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $313
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $2,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $313
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUGOAWZQ

Policy instance

Insurance contract or identification number	GLUGOAWZQ
Number of Individuals Covered	303
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $2,011
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACC DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $13,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,011
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

075879

Policy instance

Insurance contract or identification number	075879
Number of Individuals Covered	195
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $36,455
Total amount of fees paid to insurance company	USD $0
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 $36,455
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUGOAWZQ

Policy instance

Insurance contract or identification number	GUGOAWZQ
Number of Individuals Covered	71
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $2,915
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,915
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTDOAWZQ

Policy instance

Insurance contract or identification number	GLTDOAWZQ
Number of Individuals Covered	158
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $8,781
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,781
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTLOAWZQ

Policy instance

Insurance contract or identification number	GVTLOAWZQ
Number of Individuals Covered	110
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $7,612
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,612
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	74
Insurance policy start date	2015-07-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $347
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $274
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	165
Insurance policy start date	2015-07-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $797
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $3,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $598
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	115
Insurance policy start date	2015-07-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $693
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $416
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUGOAWZQ

Policy instance

Insurance contract or identification number	GLUGOAWZQ
Number of Individuals Covered	244
Insurance policy start date	2015-08-01
Insurance policy end date	2016-08-01
Total amount of commissions paid to insurance broker	USD $2,114
Total amount of fees paid to insurance company	USD $168
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACC DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $14,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,114
Amount paid for insurance broker fees	168
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUGOAWZQ

Policy instance

Insurance contract or identification number	GUGOAWZQ
Number of Individuals Covered	162
Insurance policy start date	2015-08-01
Insurance policy end date	2016-08-01
Total amount of commissions paid to insurance broker	USD $7,652
Total amount of fees paid to insurance company	USD $593
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,652
Amount paid for insurance broker fees	593
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTDOAWZQ

Policy instance

Insurance contract or identification number	GLTDOAWZQ
Number of Individuals Covered	67
Insurance policy start date	2015-08-01
Insurance policy end date	2016-08-01
Total amount of commissions paid to insurance broker	USD $2,593
Total amount of fees paid to insurance company	USD $185
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,593
Amount paid for insurance broker fees	185
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTLOAWZQ

Policy instance

Insurance contract or identification number	GVTLOAWZQ
Number of Individuals Covered	125
Insurance policy start date	2015-08-01
Insurance policy end date	2016-08-01
Total amount of commissions paid to insurance broker	USD $8,143
Total amount of fees paid to insurance company	USD $634
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,143
Amount paid for insurance broker fees	634
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	357
Insurance policy start date	2015-07-01
Insurance policy end date	2015-08-01
Total amount of commissions paid to insurance broker	USD $480
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACC DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $360
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

075879

Policy instance

Insurance contract or identification number	075879
Number of Individuals Covered	181
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $19,302
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $217,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,302
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	329
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $2,491
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACC DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $12,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,868
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

075879

Policy instance

Insurance contract or identification number	075879
Number of Individuals Covered	222
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $34,945
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $226,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,945
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	74
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $3,691
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,914
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	162
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $5,048
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $25,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,786
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	114
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $5,390
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,234
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	76
Insurance policy start date	2013-07-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $3,137
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,882
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	123
Insurance policy start date	2013-07-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $3,232
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $16,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,424
Insurance broker name	MOSAIC GROUP SERVICES

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	60
Insurance policy start date	2013-07-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $2,514
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,985
Insurance broker name	MOSAIC GROUP SERVICES

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

Policy contract number

9072571381000

Policy instance

Insurance contract or identification number	9072571381000
Number of Individuals Covered	172
Insurance policy start date	2013-04-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $2,652
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D, SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $7,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,768
Insurance broker organization code?	3
Insurance broker name	THE CASON GROUP

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

075879

Policy instance

Insurance contract or identification number	075879
Number of Individuals Covered	138
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $22,855
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $139,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,855
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50018988

Policy instance

Insurance contract or identification number	50018988
Number of Individuals Covered	187
Insurance policy start date	2013-07-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $1,591
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACC DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,193
Insurance broker name	MOSAIC GROUP SERVICES

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

075879

Policy instance

Insurance contract or identification number	075879
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $25,670
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $145,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,670
Insurance broker organization code?	3
Insurance broker name	WILLIFORD INS GROUP

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

Policy contract number

9072571381001

Policy instance

Insurance contract or identification number	9072571381001
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $3,940
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD & D
Welfare Benefit Premiums Paid to Carrier	USD $17,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,627
Insurance broker name	THE CASON GROUP

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

Policy contract number

9072571381000

Policy instance

Insurance contract or identification number	9072571381000
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $10,460
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D, SHORT TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $46,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,973
Insurance broker organization code?	3
Insurance broker name	THE CASON GROUP

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

Policy contract number

9072571381001

Policy instance

Insurance contract or identification number	9072571381001
Number of Individuals Covered	65
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $3,124
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD & D
Welfare Benefit Premiums Paid to Carrier	USD $13,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9072571381000

Policy instance

Insurance contract or identification number	9072571381000
Number of Individuals Covered	162
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $9,097
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $40,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

280-9947

Policy instance

Insurance contract or identification number	280-9947
Number of Individuals Covered	103
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $21,282
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $141,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

949-0259

Policy instance

Insurance contract or identification number	949-0259
Number of Individuals Covered	103
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $1,918
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $19,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9072571381 001

Policy instance

Insurance contract or identification number	9072571381 001
Number of Individuals Covered	76
Insurance policy start date	2011-01-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $978
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD & D
Welfare Benefit Premiums Paid to Carrier	USD $5,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SECURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68721 )

Policy contract number

39797

Policy instance

Insurance contract or identification number	39797
Number of Individuals Covered	169
Insurance policy start date	2010-04-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,234
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EASTERN LIFE & HEALTH INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 62804 )

Policy contract number

39797

Policy instance

Insurance contract or identification number	39797
Number of Individuals Covered	252
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $10,771
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

280-9660

Policy instance

Insurance contract or identification number	280-9660
Number of Individuals Covered	121
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $18,498
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $123,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

280-8361

Policy instance

Insurance contract or identification number	280-8361
Number of Individuals Covered	121
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $1,608
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $16,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

239269

Policy instance

Insurance contract or identification number	239269
Number of Individuals Covered	103
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,217
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9072571381

Policy instance

Insurance contract or identification number	9072571381
Number of Individuals Covered	169
Insurance policy start date	2011-01-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $846
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $15,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	ADAMS ELECTRIC COMPANY
Employer identification number (EIN):	560693887
NAIC Classification:	423600