401k Plan data: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN plan

SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 401k Plan overview

Plan Name	SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN
Plan identification number	502

SUNBELT FURNITURE XPRESS, INC. GROUP 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) Long-term disability cover

401k Sponsoring company profile

SUNBELT FURNITURE XPRESS, INC. has sponsored the creation of one or more 401k plans.

Company Name: SUNBELT FURNITURE XPRESS, INC.

Employer identification number (EIN): 560858955

NAIC Classification: 484200
NAIC Description: Specialized Freight Trucking

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2022-01-01 STAN FRONEBERGER 2023-08-22
502 2021-01-01 STAN FRONEBERGER 2022-07-15
502 2020-01-01 STAN FRONEBERGER 2021-07-29
502 2019-01-01 STAN FRONEBERGER 2020-09-03
502 2018-01-01 STAN FRONEBERGER 2019-10-02
502 2017-01-01
502 2016-01-01
502 2015-01-01
502 2014-01-01
502 2013-01-01
502 2012-01-01 JIM EDWARDS
502 2011-01-01 JIM EDWARDS

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
502	2022-01-01	STAN FRONEBERGER	2023-08-22
502	2021-01-01	STAN FRONEBERGER	2022-07-15
502	2020-01-01	STAN FRONEBERGER	2021-07-29
502	2019-01-01	STAN FRONEBERGER	2020-09-03
502	2018-01-01	STAN FRONEBERGER	2019-10-02
502	2017-01-01
502	2016-01-01
502	2015-01-01
502	2014-01-01
502	2013-01-01
502	2012-01-01	JIM EDWARDS
502	2011-01-01	JIM EDWARDS

Plan Statistics for SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN

401k plan membership statisitcs for SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN

Measure Date Value
2022: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 192
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 193
Total of all active and inactive participants 2022-01-01 193
2021: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 224
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 192
Number of retired or separated participants receiving benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 192
2020: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 248
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 304
Number of retired or separated participants receiving benefits 2020-01-01 1
Total of all active and inactive participants 2020-01-01 305
2019: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 245
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 247
Number of retired or separated participants receiving benefits 2019-01-01 1
Total of all active and inactive participants 2019-01-01 248
2018: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 251
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 242
Number of retired or separated participants receiving benefits 2018-01-01 3
Total of all active and inactive participants 2018-01-01 245
2017: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 277
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 251
Total of all active and inactive participants 2017-01-01 251
2016: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 273
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 277
Total of all active and inactive participants 2016-01-01 277
2015: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 267
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 273
Total of all active and inactive participants 2015-01-01 273
2014: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 243
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 267
Total of all active and inactive participants 2014-01-01 267
2013: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 244
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 243
Total of all active and inactive participants 2013-01-01 243
2012: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 237
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 244
Total of all active and inactive participants 2012-01-01 244
2011: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 237
Total of all active and inactive participants 2011-01-01 237

Measure	Date	Value
2022: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	192
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	193
Total of all active and inactive participants	2022-01-01	193
2021: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	224
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	192
Number of retired or separated participants receiving benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	192
2020: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	248
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	304
Number of retired or separated participants receiving benefits	2020-01-01	1
Total of all active and inactive participants	2020-01-01	305
2019: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	245
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	247
Number of retired or separated participants receiving benefits	2019-01-01	1
Total of all active and inactive participants	2019-01-01	248
2018: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	251
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	242
Number of retired or separated participants receiving benefits	2018-01-01	3
Total of all active and inactive participants	2018-01-01	245
2017: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	277
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	251
Total of all active and inactive participants	2017-01-01	251
2016: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	273
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	277
Total of all active and inactive participants	2016-01-01	277
2015: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	267
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	273
Total of all active and inactive participants	2015-01-01	273
2014: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	243
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	267
Total of all active and inactive participants	2014-01-01	267
2013: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	244
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	243
Total of all active and inactive participants	2013-01-01	243
2012: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	237
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	244
Total of all active and inactive participants	2012-01-01	244
2011: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	237
Total of all active and inactive participants	2011-01-01	237

Form 5500 Responses for SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN

2022: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP 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: SUNBELT FURNITURE XPRESS, INC. GROUP INSURANCE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

893073G

Policy instance

Insurance contract or identification number	893073G
Number of Individuals Covered	277
Insurance policy start date	2021-02-01
Insurance policy end date	2022-01-31
Total amount of commissions paid to insurance broker	USD $30,196
Total amount of fees paid to insurance company	USD $28,850
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $224,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,196
Amount paid for insurance broker fees	13121
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3

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

Policy contract number

14168555-1001

Policy instance

Insurance contract or identification number	14168555-1001
Number of Individuals Covered	193
Insurance policy start date	2021-02-01
Insurance policy end date	2022-01-31
Total amount of commissions paid to insurance broker	USD $65,703
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	WELLNESS
Welfare Benefit Premiums Paid to Carrier	USD $2,103,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,703
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	21
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,344
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $834
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

305514

Policy instance

Insurance contract or identification number	305514
Number of Individuals Covered	309
Insurance policy start date	2020-02-01
Insurance policy end date	2021-01-31
Total amount of commissions paid to insurance broker	USD $31,917
Total amount of fees paid to insurance company	USD $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, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $267,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,917
Insurance broker organization code?	3

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

Policy contract number

914016

Policy instance

Insurance contract or identification number	914016
Number of Individuals Covered	209
Insurance policy start date	2020-02-01
Insurance policy end date	2021-01-31
Total amount of commissions paid to insurance broker	USD $13,746
Total amount of fees paid to insurance company	USD $71,948
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,473,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,746
Amount paid for insurance broker fees	71948
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	30
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,871
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,034
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	35
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,817
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,398
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

305514

Policy instance

Insurance contract or identification number	305514
Number of Individuals Covered	334
Insurance policy start date	2019-02-01
Insurance policy end date	2020-01-31
Total amount of commissions paid to insurance broker	USD $32,754
Total amount of fees paid to insurance company	USD $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, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $270,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,754
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

914016

Policy instance

Insurance contract or identification number	914016
Number of Individuals Covered	391
Insurance policy start date	2019-02-01
Insurance policy end date	2020-01-31
Total amount of commissions paid to insurance broker	USD $14,075
Total amount of fees paid to insurance company	USD $71,228
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,253,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,075
Amount paid for insurance broker fees	71228
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	44
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,803
Total amount of fees paid to insurance company	USD $206
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,754
Amount paid for insurance broker fees	75
Insurance broker organization code?	3

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

Policy contract number

914016

Policy instance

Insurance contract or identification number	914016
Number of Individuals Covered	383
Insurance policy start date	2018-02-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $14,171
Total amount of fees paid to insurance company	USD $66,513
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,310,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,171
Amount paid for insurance broker fees	66513
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

305514

Policy instance

Insurance contract or identification number	305514
Number of Individuals Covered	303
Insurance policy start date	2018-02-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $33,152
Total amount of fees paid to insurance company	USD $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, CRITICAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $275,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,152
Insurance broker organization code?	3

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	66
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,549
Total amount of fees paid to insurance company	USD $348
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $821
Amount paid for insurance broker fees	50
Insurance broker organization code?	3

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

Policy contract number

50027775

Policy instance

Insurance contract or identification number	50027775
Number of Individuals Covered	156
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $21,407
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY INCOME PROTECTION
Welfare Benefit Premiums Paid to Carrier	USD $85,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,844
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

082009

Policy instance

Insurance contract or identification number	082009
Number of Individuals Covered	262
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $76,470
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
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 $76,470
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

50027775

Policy instance

Insurance contract or identification number	50027775
Number of Individuals Covered	301
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $1,786
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,786
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

50027775

Policy instance

Insurance contract or identification number	50027775
Number of Individuals Covered	93
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $16,636
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ECR CRITICAL CARE
Welfare Benefit Premiums Paid to Carrier	USD $23,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,872
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

50027775

Policy instance

Insurance contract or identification number	50027775
Number of Individuals Covered	226
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $19,090
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY GROUP TERM LIFE
Welfare Benefit Premiums Paid to Carrier	USD $76,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,454
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

50027775

Policy instance

Insurance contract or identification number	50027775
Number of Individuals Covered	227
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $477
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $286
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

50027775

Policy instance

Insurance contract or identification number	50027775
Number of Individuals Covered	115
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $16,513
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,908
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

GUPR0AZ7C

Policy instance

Insurance contract or identification number	GUPR0AZ7C
Number of Individuals Covered	94
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $559
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LONG-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $5,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $559
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	62
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,617
Total amount of fees paid to insurance company	USD $150
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,705
Amount paid for insurance broker fees	107
Insurance broker organization code?	3
Insurance broker name	STEPHEN C SIBEL

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

Policy contract number

GUC0AZ7C

Policy instance

Insurance contract or identification number	GUC0AZ7C
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 $807
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY SHORT-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $8,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $807
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

GVTL0AZ7C

Policy instance

Insurance contract or identification number	GVTL0AZ7C
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 $825
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VOLUNTARY LIFE AND AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $825
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00613062

Policy instance

Insurance contract or identification number	00613062
Number of Individuals Covered	251
Insurance policy start date	2016-02-01
Insurance policy end date	2017-01-31
Total amount of commissions paid to insurance broker	USD $11,704
Total amount of fees paid to insurance company	USD $50,808
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,003,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,704
Amount paid for insurance broker fees	50808
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

GLUDE0AZ7C

Policy instance

Insurance contract or identification number	GLUDE0AZ7C
Number of Individuals Covered	1
Insurance policy start date	2017-01-01
Insurance policy end date	2017-01-31
Total amount of commissions paid to insurance broker	USD $140
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $1,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

GLUG0AZ7C

Policy instance

Insurance contract or identification number	GLUG0AZ7C
Number of Individuals Covered	5
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $63
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,086
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
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

10137334 00000

Policy instance

Insurance contract or identification number	10137334 00000
Number of Individuals Covered	273
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,877
Total amount of fees paid to insurance company	USD $426
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $18,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,877
Amount paid for insurance broker fees	426
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

1D021222 00000

Policy instance

Insurance contract or identification number	1D021222 00000
Number of Individuals Covered	193
Insurance policy start date	2015-01-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $385
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $385
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

077875

Policy instance

Insurance contract or identification number	077875
Number of Individuals Covered	220
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10137333

Policy instance

Insurance contract or identification number	10137333
Number of Individuals Covered	86
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,674
Total amount of fees paid to insurance company	USD $1,311
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $46,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,674
Amount paid for insurance broker fees	1311
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

40000100012858

Policy instance

Insurance contract or identification number	40000100012858
Number of Individuals Covered	51
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,679
Total amount of fees paid to insurance company	USD $959
Other welfare benefits provided	VOL EMPLOYEE/CHILD/SPOUSE LIFE/AD&D
Welfare Benefit Premiums Paid to Carrier	USD $36,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,679
Amount paid for insurance broker fees	959
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	58
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,340
Total amount of fees paid to insurance company	USD $465
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,103
Amount paid for insurance broker fees	228
Insurance broker organization code?	3
Insurance broker name	EXSEPTIONAL SERVICES INC

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

Policy contract number

077875

Policy instance

Insurance contract or identification number	077875
Number of Individuals Covered	212
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $0
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,203,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1D021222 00000

Policy instance

Insurance contract or identification number	1D021222 00000
Number of Individuals Covered	192
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,452
Total amount of fees paid to insurance company	USD $549
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 $89,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,452
Amount paid for insurance broker fees	549
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

10137334 00000

Policy instance

Insurance contract or identification number	10137334 00000
Number of Individuals Covered	267
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,419
Total amount of fees paid to insurance company	USD $396
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	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $14,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,419
Amount paid for insurance broker fees	396
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

40000100012858

Policy instance

Insurance contract or identification number	40000100012858
Number of Individuals Covered	53
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,197
Total amount of fees paid to insurance company	USD $1,043
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	VOL EMPLOYEE/CHILD/SPOUSE LIFE/AD&D
Welfare Benefit Premiums Paid to Carrier	USD $31,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,197
Amount paid for insurance broker fees	1043
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

10137333

Policy instance

Insurance contract or identification number	10137333
Number of Individuals Covered	86
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,369
Total amount of fees paid to insurance company	USD $1,211
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	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $43,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,369
Amount paid for insurance broker fees	1211
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	46
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $8,396
Total amount of fees paid to insurance company	USD $976
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,545
Amount paid for insurance broker fees	466
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	WILLIAM L BAKER IV

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

Policy contract number

10137334 00000

Policy instance

Insurance contract or identification number	10137334 00000
Number of Individuals Covered	243
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,321
Total amount of fees paid to insurance company	USD $397
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	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $13,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,321
Amount paid for insurance broker fees	397
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

1D021222 00000

Policy instance

Insurance contract or identification number	1D021222 00000
Number of Individuals Covered	173
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,661
Total amount of fees paid to insurance company	USD $524
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 $73,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,661
Amount paid for insurance broker fees	524
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )

Policy contract number

3183170000

Policy instance

Insurance contract or identification number	3183170000
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $242
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $242
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

COVENTRY HEALTH CARE OF CAROLINAS, INC. (National Association of Insurance Commissioners NAIC id number: 95321 )

Policy contract number

3183170000

Policy instance

Insurance contract or identification number	3183170000
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,794
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
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,794
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

40000100012858

Policy instance

Insurance contract or identification number	40000100012858
Number of Individuals Covered	46
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,478
Total amount of fees paid to insurance company	USD $1,183
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	VOL EMPLOYEE/CHILD/SPOUSE LIFE/AD&D
Welfare Benefit Premiums Paid to Carrier	USD $34,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,478
Amount paid for insurance broker fees	1183
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

10137333

Policy instance

Insurance contract or identification number	10137333
Number of Individuals Covered	76
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,038
Total amount of fees paid to insurance company	USD $1,099
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	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $40,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,038
Amount paid for insurance broker fees	1099
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

OLWX5

Policy instance

Insurance contract or identification number	OLWX5
Number of Individuals Covered	51
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $14,880
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,686
Insurance broker organization code?	3
Insurance broker name	GBS MARKETING INC

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

Policy contract number

1D021222 00000

Policy instance

Insurance contract or identification number	1D021222 00000
Number of Individuals Covered	166
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,495
Total amount of fees paid to insurance company	USD $371
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 $69,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,495
Amount paid for insurance broker fees	371
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

073375

Policy instance

Insurance contract or identification number	073375
Number of Individuals Covered	201
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
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
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10137334 00000

Policy instance

Insurance contract or identification number	10137334 00000
Number of Individuals Covered	244
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,322
Total amount of fees paid to insurance company	USD $309
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	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $13,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,322
Amount paid for insurance broker fees	309
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTICE-CREWS INS AGY INC

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

Policy contract number

1D021222 00000

Policy instance

Insurance contract or identification number	1D021222 00000
Number of Individuals Covered	155
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,272
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 $45,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10137334 00000

Policy instance

Insurance contract or identification number	10137334 00000
Number of Individuals Covered	237
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $946
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	AD&D AND DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

073375

Policy instance

Insurance contract or identification number	073375
Number of Individuals Covered	189
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
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
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	SUNBELT FURNITURE XPRESS, INC.
Employer identification number (EIN):	560858955
NAIC Classification:	484200
NAIC Description:	Specialized Freight Trucking