401k Plan data: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA plan

ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 401k Plan overview

Plan Name	ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA
Plan identification number	501

ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Death benefits (include travel accident but not life insurance) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

ADDINGTON ENTERPRISES has sponsored the creation of one or more 401k plans.

Company Name: ADDINGTON ENTERPRISES

Employer identification number (EIN): 582153509

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01
501 2021-07-01
501 2020-07-01
501 2019-07-01
501 2018-07-01
501 2017-07-01 RONALD L ADDINGTON
501 2016-07-01 RONALD L ADDINGTON
501 2015-07-01 RONALD L ADDINGTON
501 2014-07-01 RONALD L ADDINGTON
501 2013-07-01 RONALD L ADDINGTON
501 2012-07-01 RONALD L ADDINGTON
501 2011-07-01 RONALD L ADDINGTON
501 2010-07-01 RONALD L ADDINGTON

Plan Statistics for ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA

401k plan membership statisitcs for ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA

Measure Date Value
2022: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2022 401k membership
Total participants, beginning-of-year 2022-07-01 577
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 119
Total of all active and inactive participants 2022-07-01 119
Total participants 2022-07-01 119
2021: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2021 401k membership
Total participants, beginning-of-year 2021-07-01 434
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 577
Total of all active and inactive participants 2021-07-01 577
Total participants 2021-07-01 577
2020: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2020 401k membership
Total participants, beginning-of-year 2020-07-01 519
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 434
Total of all active and inactive participants 2020-07-01 434
Total participants 2020-07-01 434
2019: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2019 401k membership
Total participants, beginning-of-year 2019-07-01 625
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 519
Total of all active and inactive participants 2019-07-01 519
Total participants 2019-07-01 519
2018: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2018 401k membership
Total participants, beginning-of-year 2018-07-01 681
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 625
Total of all active and inactive participants 2018-07-01 625
Total participants 2018-07-01 625
2017: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2017 401k membership
Total participants, beginning-of-year 2017-07-01 0
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 681
Total of all active and inactive participants 2017-07-01 681
Total participants 2017-07-01 681
2016: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2016 401k membership
Total participants, beginning-of-year 2016-07-01 0
Total of all active and inactive participants 2016-07-01 0
Total participants 2016-07-01 0
2015: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2015 401k membership
Total participants, beginning-of-year 2015-07-01 0
Total of all active and inactive participants 2015-07-01 0
Total participants 2015-07-01 0
2014: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2014 401k membership
Total participants, beginning-of-year 2014-07-01 0
Total of all active and inactive participants 2014-07-01 0
Total participants 2014-07-01 0
2013: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2013 401k membership
Total participants, beginning-of-year 2013-07-01 552
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 542
Total of all active and inactive participants 2013-07-01 542
Total participants 2013-07-01 0
2012: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2012 401k membership
Total participants, beginning-of-year 2012-07-01 595
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 552
Total of all active and inactive participants 2012-07-01 552
Total participants 2012-07-01 0
2011: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2011 401k membership
Total participants, beginning-of-year 2011-07-01 658
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 595
Total of all active and inactive participants 2011-07-01 595
Total participants 2011-07-01 595
2010: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2010 401k membership
Total participants, beginning-of-year 2010-07-01 859
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 658
Total of all active and inactive participants 2010-07-01 658
Total participants 2010-07-01 658

Measure	Date	Value
2022: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2022 401k membership
Total participants, beginning-of-year	2022-07-01	577
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	119
Total of all active and inactive participants	2022-07-01	119
Total participants	2022-07-01	119
2021: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2021 401k membership
Total participants, beginning-of-year	2021-07-01	434
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	577
Total of all active and inactive participants	2021-07-01	577
Total participants	2021-07-01	577
2020: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2020 401k membership
Total participants, beginning-of-year	2020-07-01	519
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	434
Total of all active and inactive participants	2020-07-01	434
Total participants	2020-07-01	434
2019: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2019 401k membership
Total participants, beginning-of-year	2019-07-01	625
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	519
Total of all active and inactive participants	2019-07-01	519
Total participants	2019-07-01	519
2018: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2018 401k membership
Total participants, beginning-of-year	2018-07-01	681
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	625
Total of all active and inactive participants	2018-07-01	625
Total participants	2018-07-01	625
2017: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2017 401k membership
Total participants, beginning-of-year	2017-07-01	0
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	681
Total of all active and inactive participants	2017-07-01	681
Total participants	2017-07-01	681
2016: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2016 401k membership
Total participants, beginning-of-year	2016-07-01	0
Total of all active and inactive participants	2016-07-01	0
Total participants	2016-07-01	0
2015: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2015 401k membership
Total participants, beginning-of-year	2015-07-01	0
Total of all active and inactive participants	2015-07-01	0
Total participants	2015-07-01	0
2014: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2014 401k membership
Total participants, beginning-of-year	2014-07-01	0
Total of all active and inactive participants	2014-07-01	0
Total participants	2014-07-01	0
2013: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2013 401k membership
Total participants, beginning-of-year	2013-07-01	552
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	542
Total of all active and inactive participants	2013-07-01	542
Total participants	2013-07-01	0
2012: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2012 401k membership
Total participants, beginning-of-year	2012-07-01	595
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	552
Total of all active and inactive participants	2012-07-01	552
Total participants	2012-07-01	0
2011: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2011 401k membership
Total participants, beginning-of-year	2011-07-01	658
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	595
Total of all active and inactive participants	2011-07-01	595
Total participants	2011-07-01	595
2010: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2010 401k membership
Total participants, beginning-of-year	2010-07-01	859
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	658
Total of all active and inactive participants	2010-07-01	658
Total participants	2010-07-01	658

Financial Data on ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA

Measure	Date	Value
2012 : ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2012 401k financial data
Total income from all sources (including contributions)	2012-06-30	$3,743,544
Total of all expenses incurred	2012-06-30	$3,743,544
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-06-30	$3,743,544
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-06-30	$3,743,544
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-06-30	No
Was this plan covered by a fidelity bond	2012-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2012-06-30	No
Contributions received from participants	2012-06-30	$1,215,588
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-06-30	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-06-30	No
Were any leases to which the plan was party in default or uncollectible	2012-06-30	No
Expenses. Payments to insurance carriers foe the provision of benefits	2012-06-30	$3,743,544
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-06-30	No
Was there a failure to transmit to the plan any participant contributions	2012-06-30	No
Has the plan failed to provide any benefit when due under the plan	2012-06-30	No
Contributions received in cash from employer	2012-06-30	$2,527,956
Did the plan have assets held for investment	2012-06-30	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-06-30	No
2011 : ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2011 401k financial data
Total income from all sources (including contributions)	2011-06-30	$3,380,636
Total of all expenses incurred	2011-06-30	$3,380,636
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-06-30	$3,380,636
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-06-30	$3,380,636
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-06-30	No
Was this plan covered by a fidelity bond	2011-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2011-06-30	No
Contributions received from participants	2011-06-30	$1,056,849
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-06-30	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-06-30	No
Were any leases to which the plan was party in default or uncollectible	2011-06-30	No
Expenses. Payments to insurance carriers foe the provision of benefits	2011-06-30	$3,380,636
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-06-30	No
Was there a failure to transmit to the plan any participant contributions	2011-06-30	No
Has the plan failed to provide any benefit when due under the plan	2011-06-30	No
Contributions received in cash from employer	2011-06-30	$2,323,787
Did the plan have assets held for investment	2011-06-30	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-06-30	No

Form 5500 Responses for ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA

2022: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2021: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2011: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Submission has been amended	Yes
2011-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2010: ADDINGTON ENTERPRISES EMPLOYEE WELFARE BENEFIT PLA 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	First time form 5500 has been submitted	Yes
2010-07-01	Submission has been amended	Yes
2010-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

L03306

Policy instance

Insurance contract or identification number	L03306
Insurance policy start date	2022-08-01
Insurance policy end date	2023-07-31
Total amount of commissions paid to insurance broker	USD $21,687
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $422,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,687
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Insurance policy start date	2022-08-01
Insurance policy end date	2023-07-31
Total amount of commissions paid to insurance broker	USD $9,125
Total amount of fees paid to insurance company	USD $1,636
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,900
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Amount paid for insurance broker fees	1636

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

L03306

Policy instance

Insurance contract or identification number	L03306
Number of Individuals Covered	577
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $65,139
Total amount of fees paid to insurance company	USD $1,285
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,348,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,139
Amount paid for insurance broker fees	1285
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Number of Individuals Covered	100
Insurance policy start date	2021-08-01
Insurance policy end date	2022-07-31
Total amount of commissions paid to insurance broker	USD $14,048
Total amount of fees paid to insurance company	USD $4,470
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,986
Amount paid for insurance broker fees	4470
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

0918465

Policy instance

Insurance contract or identification number	0918465
Number of Individuals Covered	254
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of fees paid to insurance company	USD $54,005
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,671,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	54005
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Number of Individuals Covered	180
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $20,153
Total amount of fees paid to insurance company	USD $1,191
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $146,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,699
Amount paid for insurance broker fees	1191
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Number of Individuals Covered	199
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $28,149
Total amount of fees paid to insurance company	USD $12,410
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $210,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,149
Amount paid for insurance broker fees	12410
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

SE1F0830

Policy instance

Insurance contract or identification number	SE1F0830
Number of Individuals Covered	54
Insurance policy start date	2019-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $561
Welfare Benefit Premiums Paid to Carrier	USD $11,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $561
Insurance broker organization code?	3

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

Policy contract number

0918465

Policy instance

Insurance contract or identification number	0918465
Number of Individuals Covered	266
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $3,200
Total amount of fees paid to insurance company	USD $64,631
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,950,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,200
Amount paid for insurance broker fees	64631
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Number of Individuals Covered	198
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $15,651
Total amount of fees paid to insurance company	USD $5,033
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,651
Amount paid for insurance broker fees	5033
Insurance broker organization code?	3

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	2
Insurance policy start date	2001-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $1,299
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,299
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	623
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $71,515
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,315,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $71,515
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00529163

Policy instance

Insurance contract or identification number	00529163
Number of Individuals Covered	169
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $13,656
Total amount of fees paid to insurance company	USD $301
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $137,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,271
Insurance broker organization code?	3
Amount paid for insurance broker fees	301

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Number of Individuals Covered	209
Insurance policy start date	2017-08-07
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $15,839
Total amount of fees paid to insurance company	USD $1,057
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	11
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $1,477
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	670
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $81,349
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,270,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00529163

Policy instance

Insurance contract or identification number	00529163
Number of Individuals Covered	189
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $11,986
Total amount of fees paid to insurance company	USD $221
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $116,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	148
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $17,179
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $409,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,179
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES

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

Policy contract number

E3083029

Policy instance

Insurance contract or identification number	E3083029
Number of Individuals Covered	261
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $31,489
Total amount of fees paid to insurance company	USD $1,287
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $195,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,489
Amount paid for insurance broker fees	1287
Insurance broker organization code?	3
Insurance broker name	COLONIAL LIFE

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	911
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $113,104
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,695,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $113,104
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Number of Individuals Covered	113
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $18,976
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $452,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,976
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Number of Individuals Covered	711
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $23,031
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $208,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,031
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES, INC

COTTON STATES LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62537 )

Policy contract number

Policy instance

Insurance contract or identification number	UL
Number of Individuals Covered	87
Insurance policy start date	2015-08-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $1,440
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,440
Insurance broker organization code?	3
Insurance broker name	COTTON STATES LIFE INSURANCE CO

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	151
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $16,801
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $387,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,801
Insurance broker name	TIS INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	883
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $109,280
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,522,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $109,280
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Number of Individuals Covered	686
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $22,818
Total amount of fees paid to insurance company	USD $8,877
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $204,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,818
Amount paid for insurance broker fees	8877
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES, INC

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Number of Individuals Covered	138
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $24,192
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $558,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,192
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES

COTTON STATES LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62537 )

Policy contract number

Policy instance

Insurance contract or identification number	UL
Number of Individuals Covered	94
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $1,641
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,641
Insurance broker organization code?	3
Insurance broker name	COTTON STATES LIFE INSURANCE CO

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

Policy contract number

E3083029

Policy instance

Insurance contract or identification number	E3083029
Number of Individuals Covered	254
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $29,171
Total amount of fees paid to insurance company	USD $558
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $204,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,171
Amount paid for insurance broker fees	558
Insurance broker organization code?	3
Insurance broker name	COLONIAL LIFE

COTTON STATES LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62537 )

Policy contract number

Policy instance

Insurance contract or identification number	UL
Number of Individuals Covered	108
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $2,082
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $50,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,082
Insurance broker organization code?	3
Insurance broker name	COTTON STATES LIFE INSURANCE CO

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00489631

Policy instance

Insurance contract or identification number	00489631
Number of Individuals Covered	686
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $20,500
Total amount of fees paid to insurance company	USD $4,254
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,500
Amount paid for insurance broker fees	4254
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES, INC

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Number of Individuals Covered	134
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $24,973
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $526,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,973
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	1032
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $137,478
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,895,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $137,478
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES

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

Policy contract number

E3083029

Policy instance

Insurance contract or identification number	E3083029
Number of Individuals Covered	250
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $28,348
Total amount of fees paid to insurance company	USD $1,874
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $192,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,348
Amount paid for insurance broker fees	1874
Insurance broker organization code?	3
Insurance broker name	COLONIAL LIFE

COTTON STATES LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62537 )

Policy contract number

Policy instance

Insurance contract or identification number	UL
Number of Individuals Covered	137
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $2,479
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $80
Insurance broker organization code?	3
Insurance broker name	BYRON BROCK AGENCY

KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )

Policy contract number

AS001-0178-KCL

Policy instance

Insurance contract or identification number	AS001-0178-KCL
Number of Individuals Covered	16
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $802
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES INC

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

Policy contract number

5301784

Policy instance

Insurance contract or identification number	5301784
Number of Individuals Covered	1179
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $9,153
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $94,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,153
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES INC

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

Policy contract number

5301692

Policy instance

Insurance contract or identification number	5301692
Number of Individuals Covered	675
Insurance policy start date	2012-07-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $6,507
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $69,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,507
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-034269

Policy instance

Insurance contract or identification number	010-034269
Number of Individuals Covered	235
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $1,087
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,087
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES INC

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	1061
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $85,056
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,717,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $85,056
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES INC

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

Policy contract number

E3038478

Policy instance

Insurance contract or identification number	E3038478
Number of Individuals Covered	274
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $31,550
Total amount of fees paid to insurance company	USD $909
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $213,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $533
Insurance broker organization code?	3
Amount paid for insurance broker fees	105
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	MICKEY R OWEN

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

GA6012

Policy instance

Insurance contract or identification number	GA6012
Number of Individuals Covered	129
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $16,216
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $435,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,216
Insurance broker organization code?	3
Insurance broker name	TIS INSURANCE SERVICES INC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-034269

Policy instance

Insurance contract or identification number	010-034269
Number of Individuals Covered	255
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $1,219
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Number of Individuals Covered	1158
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $146,988
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,984,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $95
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5301784

Policy instance

Insurance contract or identification number	5301784
Number of Individuals Covered	1217
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $8,857
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $91,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Number of Individuals Covered	133
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $27,718
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $473,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Number of Individuals Covered	162
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $29,801
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $504,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Number of Individuals Covered	1302
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $97
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $137,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

1000419100

Policy instance

Insurance contract or identification number	1000419100
Number of Individuals Covered	1258
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $148,842
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,025,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-034269

Policy instance

Insurance contract or identification number	010-034269
Number of Individuals Covered	261
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $1,174
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5301784

Policy instance

Insurance contract or identification number	5301784
Number of Individuals Covered	385
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $1,604
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $19,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	ADDINGTON ENTERPRISES
Employer identification number (EIN):	582153509
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities