401k Plan data: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN plan

JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN
Plan identification number	502

JERVEY EYE GROUP, P.A. 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

JERVEY EYE GROUP, P.A. has sponsored the creation of one or more 401k plans.

Company Name: JERVEY EYE GROUP, P.A.

Employer identification number (EIN): 570996196

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2022-01-01
502 2021-01-01
502 2020-01-01
502 2019-01-01
502 2018-01-01 LEONARDO DENARO LEONARDO DENARO 2019-07-22
502 2017-01-01 LEONARDO DENARO LEONARDO DENARO 2018-07-27
502 2016-01-01 ANTHONY P. JOHNSON ANTHONY P. JOHNSON 2017-07-12
502 2015-01-01 ANTHONY P. JOHNSON ANTHONY P. JOHNSON 2016-07-19
502 2014-01-01 ANTHONY P. JOHNSON ANTHONY P. JOHNSON 2015-08-11
502 2013-01-01 ANTHONY P. JOHNSON ANTHONY P. JOHNSON 2014-05-15
502 2012-01-01 ANTHONY P. JOHNSON ANTHONY P. JOHNSON 2013-06-05
502 2011-01-01 ANTHONY P. JOHNSON
502 2010-01-01 ANTHONY P. JOHNSON
502 2009-01-01 ANTHONY P. JOHNSON
502 2009-01-01 ANTHONY P. JOHNSON

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
502	2022-01-01
502	2021-01-01
502	2020-01-01
502	2019-01-01
502	2018-01-01	LEONARDO DENARO	LEONARDO DENARO	2019-07-22
502	2017-01-01	LEONARDO DENARO	LEONARDO DENARO	2018-07-27
502	2016-01-01	ANTHONY P. JOHNSON	ANTHONY P. JOHNSON	2017-07-12
502	2015-01-01	ANTHONY P. JOHNSON	ANTHONY P. JOHNSON	2016-07-19
502	2014-01-01	ANTHONY P. JOHNSON	ANTHONY P. JOHNSON	2015-08-11
502	2013-01-01	ANTHONY P. JOHNSON	ANTHONY P. JOHNSON	2014-05-15
502	2012-01-01	ANTHONY P. JOHNSON	ANTHONY P. JOHNSON	2013-06-05
502	2011-01-01	ANTHONY P. JOHNSON
502	2010-01-01	ANTHONY P. JOHNSON
502	2009-01-01	ANTHONY P. JOHNSON
502	2009-01-01	ANTHONY P. JOHNSON

Plan Statistics for JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN

401k plan membership statisitcs for JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN

Measure Date Value
2022: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 126
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 126
2021: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 111
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 128
Number of retired or separated participants receiving benefits 2021-01-01 1
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 129
2020: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 111
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 111
2019: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 159
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 135
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 135
2018: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 164
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 159
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 159
2017: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 164
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 164
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 164
2016: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 164
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 164
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 164
2015: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 156
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 164
Number of retired or separated participants receiving benefits 2015-01-01 1
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 165
2014: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 221
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 156
Number of retired or separated participants receiving benefits 2014-01-01 1
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 157
2013: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 339
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 221
Total of all active and inactive participants 2013-01-01 221
2012: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 165
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 339
Total of all active and inactive participants 2012-01-01 339
2011: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 256
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 165
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 165
2010: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 222
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 256
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 256
2009: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 150
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 222
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 222

Measure	Date	Value
2022: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	126
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	126
2021: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	111
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	128
Number of retired or separated participants receiving benefits	2021-01-01	1
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	129
2020: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	111
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	111
2019: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	159
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	135
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	135
2018: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	164
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	159
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	159
2017: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	164
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	164
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	164
2016: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	164
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	164
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	164
2015: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	156
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	164
Number of retired or separated participants receiving benefits	2015-01-01	1
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	165
2014: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	221
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	156
Number of retired or separated participants receiving benefits	2014-01-01	1
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	157
2013: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	339
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	221
Total of all active and inactive participants	2013-01-01	221
2012: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	165
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	339
Total of all active and inactive participants	2012-01-01	339
2011: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	256
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	165
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	165
2010: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	222
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	256
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	256
2009: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	150
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	222
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	222

Form 5500 Responses for JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN

2022: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: JERVEY EYE GROUP, P.A. WELFARE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: JERVEY EYE GROUP, P.A. WELFARE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: JERVEY EYE GROUP, P.A. WELFARE BENEFIT 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 funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: JERVEY EYE GROUP, P.A. WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

SGM609331

Policy instance

Insurance contract or identification number	SGM609331
Number of Individuals Covered	126
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,956
Total amount of fees paid to insurance company	USD $4
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,956
Amount paid for insurance broker fees	4
Additional information about fees paid to insurance broker	STANDARD COMMISSIONS
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

25-84698-00

Policy instance

Insurance contract or identification number	25-84698-00
Number of Individuals Covered	103
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,241,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

3342399

Policy instance

Insurance contract or identification number	3342399
Number of Individuals Covered	96
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,852
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,852
Insurance broker organization code?	3

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

Policy contract number

CI 961372

Policy instance

Insurance contract or identification number	CI 961372
Number of Individuals Covered	28
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,373
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $15,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,373
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	9
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,181
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $17,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,651
Insurance broker organization code?	3

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

Policy contract number

VDT602362

Policy instance

Insurance contract or identification number	VDT602362
Number of Individuals Covered	41
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,613
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,613
Additional information about fees paid to insurance broker	STANDARD COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

SGD609970

Policy instance

Insurance contract or identification number	SGD609970
Number of Individuals Covered	126
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,442
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,442
Additional information about fees paid to insurance broker	STANDARD COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

AI 961442

Policy instance

Insurance contract or identification number	AI 961442
Number of Individuals Covered	10
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,440
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $11,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,440
Insurance broker organization code?	3

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

Policy contract number

3342399

Policy instance

Insurance contract or identification number	3342399
Number of Individuals Covered	98
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,123
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,123
Insurance broker organization code?	3

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

Policy contract number

SGM609331

Policy instance

Insurance contract or identification number	SGM609331
Number of Individuals Covered	128
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,960
Total amount of fees paid to insurance company	USD $825
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $33,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,960
Amount paid for insurance broker fees	825
Additional information about fees paid to insurance broker	STANDARD COMMISSIONS
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	9
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,330
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $19,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,775
Insurance broker organization code?	3

FLORES AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

Policy instance

Number of Individuals Covered	24
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Other welfare benefits provided	REIMBURSEMENT ACCOUNTS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VDT602362

Policy instance

Insurance contract or identification number	VDT602362
Number of Individuals Covered	47
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,131
Total amount of fees paid to insurance company	USD $282
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,131
Amount paid for insurance broker fees	282
Additional information about fees paid to insurance broker	STANDARD COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

SGD609970

Policy instance

Insurance contract or identification number	SGD609970
Number of Individuals Covered	128
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,290
Total amount of fees paid to insurance company	USD $316
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,290
Amount paid for insurance broker fees	316
Additional information about fees paid to insurance broker	STANDARD COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

CI 961372

Policy instance

Insurance contract or identification number	CI 961372
Number of Individuals Covered	29
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,045
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $16,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,045
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

25-84698-00

Policy instance

Insurance contract or identification number	25-84698-00
Number of Individuals Covered	101
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $992,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

AI 961442

Policy instance

Insurance contract or identification number	AI 961442
Number of Individuals Covered	35
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,184
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $11,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,184
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

25-84698-00

Policy instance

Insurance contract or identification number	25-84698-00
Number of Individuals Covered	104
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,062,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

3342399

Policy instance

Insurance contract or identification number	3342399
Number of Individuals Covered	104
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,999
Total amount of fees paid to insurance company	USD $648
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,999
Amount paid for insurance broker fees	648
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3

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

Policy contract number

SGM609331

Policy instance

Insurance contract or identification number	SGM609331
Number of Individuals Covered	111
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,847
Total amount of fees paid to insurance company	USD $608
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $18,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,847
Amount paid for insurance broker fees	608
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	11
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,741
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $23,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,951
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $41
Other welfare benefits provided	CANCER COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30
Insurance broker organization code?	3

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

Policy contract number

CI 961372

Policy instance

Insurance contract or identification number	CI 961372
Number of Individuals Covered	32
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,401
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $7,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,401
Insurance broker organization code?	3

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

Policy contract number

VDT602362

Policy instance

Insurance contract or identification number	VDT602362
Number of Individuals Covered	53
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,576
Total amount of fees paid to insurance company	USD $733
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,576
Amount paid for insurance broker fees	733
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL35284

Policy instance

Insurance contract or identification number	HCL35284
Number of Individuals Covered	111
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $13,894
Welfare Benefit Premiums Paid to Carrier	USD $277,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,894
Insurance broker organization code?	3

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

Policy contract number

SGD609970

Policy instance

Insurance contract or identification number	SGD609970
Number of Individuals Covered	111
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,279
Total amount of fees paid to insurance company	USD $984
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,279
Amount paid for insurance broker fees	984
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

AI 961442

Policy instance

Insurance contract or identification number	AI 961442
Number of Individuals Covered	36
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,133
Other welfare benefits provided	ACCIDENTAL INJURY
Welfare Benefit Premiums Paid to Carrier	USD $5,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,133
Insurance broker organization code?	3

FLORES AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

Policy instance

Number of Individuals Covered	24
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Other welfare benefits provided	REIMBURSEMENT ACCOUNTS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

03-84698-99

Policy instance

Insurance contract or identification number	03-84698-99
Number of Individuals Covered	112
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,483,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

3342399

Policy instance

Insurance contract or identification number	3342399
Number of Individuals Covered	98
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,316
Total amount of fees paid to insurance company	USD $1,140
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,316
Amount paid for insurance broker fees	1140
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker organization code?	3

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

Policy contract number

SGM609331

Policy instance

Insurance contract or identification number	SGM609331
Number of Individuals Covered	135
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,842
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,842
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $37
Other welfare benefits provided	CANCER COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

R0730531

Policy instance

Insurance contract or identification number	R0730531
Number of Individuals Covered	102
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,033
Total amount of fees paid to insurance company	USD $172
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $29,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,033
Amount paid for insurance broker fees	172
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

FLORES AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

Policy instance

Number of Individuals Covered	27
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Other welfare benefits provided	REIMBURSEMENT ACCOUNTS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

VDT602362

Policy instance

Insurance contract or identification number	VDT602362
Number of Individuals Covered	47
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,266
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,266
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

905244

Policy instance

Insurance contract or identification number	905244
Number of Individuals Covered	113
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,557
Welfare Benefit Premiums Paid to Carrier	USD $315,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,557
Insurance broker organization code?	3

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

Policy contract number

SGD609970

Policy instance

Insurance contract or identification number	SGD609970
Number of Individuals Covered	131
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,734
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,734
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

000000662471

Policy instance

Insurance contract or identification number	000000662471
Number of Individuals Covered	159
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,645
Total amount of fees paid to insurance company	USD $1,281
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $58,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,376
Amount paid for insurance broker fees	843
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	25
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,492
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $25,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,368
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $34
Other welfare benefits provided	CANCER COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $683
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
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

000000662472

Policy instance

Insurance contract or identification number	000000662472
Number of Individuals Covered	85
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,913
Total amount of fees paid to insurance company	USD $517
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,243
Amount paid for insurance broker fees	341
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

657867

Policy instance

Insurance contract or identification number	657867
Number of Individuals Covered	62
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,010
Total amount of fees paid to insurance company	USD $1,768
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,039
Amount paid for insurance broker fees	1188
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

905244

Policy instance

Insurance contract or identification number	905244
Number of Individuals Covered	128
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $53,376
Total amount of fees paid to insurance company	USD $8,726
Welfare Benefit Premiums Paid to Carrier	USD $410,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,178
Amount paid for insurance broker fees	8726
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

645471

Policy instance

Insurance contract or identification number	645471
Number of Individuals Covered	120
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $11,833
Total amount of fees paid to insurance company	USD $4,551
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,881
Amount paid for insurance broker fees	3031
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

03-84698-99

Policy instance

Insurance contract or identification number	03-84698-99
Number of Individuals Covered	130
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,262
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,331,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,262
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

03-84698-00

Policy instance

Insurance contract or identification number	03-84698-00
Number of Individuals Covered	142
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $55,961
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,563,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,961
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

25-85439-00

Policy instance

Insurance contract or identification number	25-85439-00
Number of Individuals Covered	132
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $9,772
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9772
Additional information about fees paid to insurance broker	AGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

000000662471

Policy instance

Insurance contract or identification number	000000662471
Number of Individuals Covered	164
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,667
Total amount of fees paid to insurance company	USD $1,281
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $64,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,667
Amount paid for insurance broker fees	1281
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	9
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,010
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $22,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,342
Insurance broker organization code?	3
Insurance broker name	PLAN SOURCE BENEFIT ADMINISTRATION

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $37
Other welfare benefits provided	CANCER COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27
Insurance broker organization code?	3
Insurance broker name	KEITH TOBIAS

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

000000662472

Policy instance

Insurance contract or identification number	000000662472
Number of Individuals Covered	80
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,615
Total amount of fees paid to insurance company	USD $486
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,615
Amount paid for insurance broker fees	486
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

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

Policy contract number

00001D024946

Policy instance

Insurance contract or identification number	00001D024946
Number of Individuals Covered	138
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,327
Total amount of fees paid to insurance company	USD $1,037
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,327
Amount paid for insurance broker fees	1037
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $41
Other welfare benefits provided	CANCER COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30
Insurance broker organization code?	3
Insurance broker name	KEITH TOBIAS

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	19
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,172
Total amount of fees paid to insurance company	USD $352
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $17,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,643
Amount paid for insurance broker fees	352
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	PLAN SOURCE BENEFIT ADMINISTRATION

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

03-84698-00

Policy instance

Insurance contract or identification number	03-84698-00
Number of Individuals Covered	141
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $48,888
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,353,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48,888
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

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

Policy contract number

10165831 00000

Policy instance

Insurance contract or identification number	10165831 00000
Number of Individuals Covered	164
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,881
Total amount of fees paid to insurance company	USD $1,293
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,881
Amount paid for insurance broker fees	1293
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARSH MCLENNAN AGENCY LLC

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

Policy contract number

000010165830

Policy instance

Insurance contract or identification number	000010165830
Number of Individuals Covered	164
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $810
Total amount of fees paid to insurance company	USD $186
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $810
Amount paid for insurance broker fees	186
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $37
Other welfare benefits provided	CANCER COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27
Insurance broker organization code?	3
Insurance broker name	KEITH TOBIAS

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

Policy contract number

10165831 00000

Policy instance

Insurance contract or identification number	10165831 00000
Number of Individuals Covered	156
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,520
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,520
Insurance broker organization code?	3
Insurance broker name	MARSH MCLENNAN AGENCY LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	19
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,238
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $16,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,733
Insurance broker organization code?	3
Insurance broker name	PLAN SOURCE BENEFIT ADMINISTRATION

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

Policy contract number

000010165830

Policy instance

Insurance contract or identification number	000010165830
Number of Individuals Covered	156
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $794
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $794
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

03-84698-00

Policy instance

Insurance contract or identification number	03-84698-00
Number of Individuals Covered	140
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $49,348
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,164,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,348
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

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

Policy contract number

00001D024946

Policy instance

Insurance contract or identification number	00001D024946
Number of Individuals Covered	136
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $8,856
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,856
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $40
Total amount of fees paid to insurance company	USD $1
Other welfare benefits provided	CANCER COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30
Insurance broker organization code?	3
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	NON-CASH INCENTIVES
Insurance broker name	KEITH TOBIAS

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05775034

Policy instance

Insurance contract or identification number	TM05775034
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,144
Total amount of fees paid to insurance company	USD $63
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 $1,144
Amount paid for insurance broker fees	63
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

000010165830

Policy instance

Insurance contract or identification number	000010165830
Number of Individuals Covered	212
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,072
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,963
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,072
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

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

Policy contract number

00001D024946

Policy instance

Insurance contract or identification number	00001D024946
Number of Individuals Covered	127
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,068
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $74,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,068
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

25-84698-00

Policy instance

Insurance contract or identification number	25-84698-00
Number of Individuals Covered	221
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $58,828
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,149,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,828
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

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

Policy contract number

10165831 00000

Policy instance

Insurance contract or identification number	10165831 00000
Number of Individuals Covered	156
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,560
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,560
Insurance broker organization code?	3
Insurance broker name	MARSH MCLENNAN AGENCY LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	19
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,929
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $14,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,506
Insurance broker organization code?	3
Insurance broker name	PLAN SOURCE BENEFIT ADMINISTRATION

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5447507

Policy instance

Insurance contract or identification number	5447507
Number of Individuals Covered	150
Insurance policy start date	2011-10-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $9,794
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,794
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	20
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,369
Other welfare benefits provided	LONG TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $13,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,962
Insurance broker organization code?	3
Insurance broker name	PLAN SOURCE BENEFIT ADMINISTRATION

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

087146

Policy instance

Insurance contract or identification number	087146
Number of Individuals Covered	154
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,286
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,031
Insurance broker organization code?	3
Insurance broker name	PLANSOURCE BENEFIT ADMINISTRATION

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05775034

Policy instance

Insurance contract or identification number	TM05775034
Number of Individuals Covered	339
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,236
Total amount of fees paid to insurance company	USD $26
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,236
Insurance broker organization code?	3
Amount paid for insurance broker fees	26
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker name	MARSH & MCLENNAN AGENCY LLC

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

Policy contract number

10165831 00000

Policy instance

Insurance contract or identification number	10165831 00000
Number of Individuals Covered	155
Insurance policy start date	2012-10-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,372
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,372
Insurance broker organization code?	3
Insurance broker name	MARSH MCLENNAN AGENCY LLC

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $34
Total amount of fees paid to insurance company	USD $1
Other welfare benefits provided	CANCER COVERAGE
Welfare Benefit Premiums Paid to Carrier	USD $683
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	NON-CASH INCENTIVES
Insurance broker name	KEITH TOBIAS

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

25-84698-00

Policy instance

Insurance contract or identification number	25-84698-00
Number of Individuals Covered	220
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $59,330
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,153,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,330
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5447507

Policy instance

Insurance contract or identification number	5447507
Number of Individuals Covered	152
Insurance policy start date	2010-10-01
Insurance policy end date	2011-09-30
Total amount of commissions paid to insurance broker	USD $10,041
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $66,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )

Policy contract number

25-84698

Policy instance

Insurance contract or identification number	25-84698
Number of Individuals Covered	246
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $54,097
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,004,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	19
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,127
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05775034

Policy instance

Insurance contract or identification number	TM05775034
Number of Individuals Covered	351
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,999
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $59,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

087146

Policy instance

Insurance contract or identification number	087146
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 $1,155
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7394125

Policy instance

Insurance contract or identification number	E7394125
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $49
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	CANCER COVERAGE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $898
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

715781

Policy instance

Insurance contract or identification number	715781
Number of Individuals Covered	256
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $65,414
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,109,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,414
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5447507

Policy instance

Insurance contract or identification number	5447507
Number of Individuals Covered	156
Insurance policy start date	2009-10-01
Insurance policy end date	2010-09-30
Total amount of commissions paid to insurance broker	USD $9,715
Total amount of fees paid to insurance company	USD $149
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $64,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,715
Amount paid for insurance broker fees	149
Additional information about fees paid to insurance broker	PRODUCER PROGRAM PAYMENT
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

087146

Policy instance

Insurance contract or identification number	087146
Number of Individuals Covered	160
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,174
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,174
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

401438

Policy instance

Insurance contract or identification number	401438
Number of Individuals Covered	20
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,196
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,196
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

106413

Policy instance

Insurance contract or identification number	106413
Number of Individuals Covered	0
Insurance policy start date	2009-10-01
Insurance policy end date	2010-10-01
Total amount of commissions paid to insurance broker	USD $1
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1
Insurance broker organization code?	3
Insurance broker name	ROSENFELD EINSTEIN EMPLOYEE BENEFIT

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Company Name:	JERVEY EYE GROUP, P.A.
Employer identification number (EIN):	570996196
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)