401k Plan data: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN plan

NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN
Plan identification number	503

NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

NEWFIELDS COMPANIES, LLC has sponsored the creation of one or more 401k plans.

Company Name: NEWFIELDS COMPANIES, LLC

Employer identification number (EIN): 582585034

NAIC Classification: 541330
NAIC Description: Engineering Services

Additional information about NEWFIELDS COMPANIES, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 5653694

More information about NEWFIELDS COMPANIES, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-01-01 TONI WYNN 2023-10-16
503 2021-01-01 TONI WYNN 2022-10-17
503 2020-01-01 ELI MCKEE 2021-10-14
503 2019-01-01 ERIC SALNAS 2020-10-09
503 2018-01-01 ERIC SALNAS 2019-10-14
503 2017-01-01
503 2016-01-01
503 2015-01-01
503 2014-01-01
503 2013-01-01
503 2012-01-01 GINGER L. HICKS

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
503	2022-01-01	TONI WYNN	2023-10-16
503	2021-01-01	TONI WYNN	2022-10-17
503	2020-01-01	ELI MCKEE	2021-10-14
503	2019-01-01	ERIC SALNAS	2020-10-09
503	2018-01-01	ERIC SALNAS	2019-10-14
503	2017-01-01
503	2016-01-01
503	2015-01-01
503	2014-01-01
503	2013-01-01
503	2012-01-01	GINGER L. HICKS

Plan Statistics for NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN

401k plan membership statisitcs for NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN

Measure Date Value
2022: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 234
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 232
Total of all active and inactive participants 2022-01-01 232
2021: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 227
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 234
Total of all active and inactive participants 2021-01-01 234
2020: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 223
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 227
Total of all active and inactive participants 2020-01-01 227
2019: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 215
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 223
Total of all active and inactive participants 2019-01-01 223
2018: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 199
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 215
Total of all active and inactive participants 2018-01-01 215
2017: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 196
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 199
Total of all active and inactive participants 2017-01-01 199
2016: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 195
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 196
Total of all active and inactive participants 2016-01-01 196
2015: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 381
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 195
Total of all active and inactive participants 2015-01-01 195
2014: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 199
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 381
Total of all active and inactive participants 2014-01-01 381
2013: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 188
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 199
Total of all active and inactive participants 2013-01-01 199
2012: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 164
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 188
Total of all active and inactive participants 2012-01-01 188
Total participants 2012-01-01 0

Measure	Date	Value
2022: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	234
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	232
Total of all active and inactive participants	2022-01-01	232
2021: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	227
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	234
Total of all active and inactive participants	2021-01-01	234
2020: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	223
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	227
Total of all active and inactive participants	2020-01-01	227
2019: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	215
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	223
Total of all active and inactive participants	2019-01-01	223
2018: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	199
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	215
Total of all active and inactive participants	2018-01-01	215
2017: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	196
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	199
Total of all active and inactive participants	2017-01-01	199
2016: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	195
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	196
Total of all active and inactive participants	2016-01-01	196
2015: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	381
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	195
Total of all active and inactive participants	2015-01-01	195
2014: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	199
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	381
Total of all active and inactive participants	2014-01-01	381
2013: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	188
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	199
Total of all active and inactive participants	2013-01-01	199
2012: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	164
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	188
Total of all active and inactive participants	2012-01-01	188
Total participants	2012-01-01	0

Form 5500 Responses for NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN

2022: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2021: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2020: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2019: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2018: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2017: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2016: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2015: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2014: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2013: NEWFIELDS COMPANIES, LLC FULLY INSURED 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 benefit arrangement – Insurance	Yes
2012: NEWFIELDS COMPANIES, LLC FULLY INSURED WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GVTL0AWLD

Policy instance

Insurance contract or identification number	GVTL0AWLD
Number of Individuals Covered	83
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $7,629
Total amount of fees paid to insurance company	USD $6,484
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $50,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,258
Insurance broker organization code?	3
Amount paid for insurance broker fees	4019
Additional information about fees paid to insurance broker	OTHER COMPENSATION

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

136-421087

Policy instance

Insurance contract or identification number	136-421087
Number of Individuals Covered	175
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $15,505
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $155,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,860
Insurance broker organization code?	3

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

Policy contract number

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	220
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $3,933
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP LT CARE
Welfare Benefit Premiums Paid to Carrier	USD $27,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,760
Insurance broker organization code?	3

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

Policy contract number

GLUG0AWLD

Policy instance

Insurance contract or identification number	GLUG0AWLD
Number of Individuals Covered	223
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,614
Total amount of fees paid to insurance company	USD $1,737
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,758
Insurance broker organization code?	3
Amount paid for insurance broker fees	976

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

Policy contract number

10027981001

Policy instance

Insurance contract or identification number	10027981001
Number of Individuals Covered	6
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $50
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VISION - COBRA
Welfare Benefit Premiums Paid to Carrier	USD $492
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

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

Policy contract number

GUG0AWLD

Policy instance

Insurance contract or identification number	GUG0AWLD
Number of Individuals Covered	223
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $5,052
Total amount of fees paid to insurance company	USD $3,711
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,393
Insurance broker organization code?	3
Amount paid for insurance broker fees	2179

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

Policy contract number

GLTD0AWLD

Policy instance

Insurance contract or identification number	GLTD0AWLD
Number of Individuals Covered	223
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $9,421
Total amount of fees paid to insurance company	USD $6,871
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,323
Insurance broker organization code?	3
Amount paid for insurance broker fees	4023

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

Policy contract number

GUNJ0AWLD

Policy instance

Insurance contract or identification number	GUNJ0AWLD
Number of Individuals Covered	11
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $452
Total amount of fees paid to insurance company	USD $209
Other welfare benefits provided	SHORT TERM DISABLILITY
Welfare Benefit Premiums Paid to Carrier	USD $3,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $305
Insurance broker organization code?	3
Amount paid for insurance broker fees	173

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

Policy contract number

10027971001

Policy instance

Insurance contract or identification number	10027971001
Number of Individuals Covered	271
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,029
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,049
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

136-421087

Policy instance

Insurance contract or identification number	136-421087
Number of Individuals Covered	429
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $15,606
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $156,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,606
Insurance broker organization code?	3

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

Policy contract number

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	254
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $4,629
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP LT CARE/GROUP IND. LTC
Welfare Benefit Premiums Paid to Carrier	USD $30,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,629
Insurance broker organization code?	3

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

Policy contract number

GLUG0AWLD

Policy instance

Insurance contract or identification number	GLUG0AWLD
Number of Individuals Covered	245
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $2,441
Total amount of fees paid to insurance company	USD $1,454
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $16,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,441
Insurance broker organization code?	3
Amount paid for insurance broker fees	933

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

Policy contract number

GVTL0AWLD

Policy instance

Insurance contract or identification number	GVTL0AWLD
Number of Individuals Covered	99
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $10,047
Total amount of fees paid to insurance company	USD $6,288
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $66,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,047
Insurance broker organization code?	3
Amount paid for insurance broker fees	4143

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

Policy contract number

GUG0AWLD

Policy instance

Insurance contract or identification number	GUG0AWLD
Number of Individuals Covered	245
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $5,447
Total amount of fees paid to insurance company	USD $3,238
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,447
Insurance broker organization code?	3
Amount paid for insurance broker fees	2076

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

Policy contract number

GLTD0AWLD

Policy instance

Insurance contract or identification number	GLTD0AWLD
Number of Individuals Covered	245
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $10,057
Total amount of fees paid to insurance company	USD $6,039
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,057
Insurance broker organization code?	3
Amount paid for insurance broker fees	3894
Additional information about fees paid to insurance broker	ADMINISTRATION

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

Policy contract number

GUNJ0AWLD

Policy instance

Insurance contract or identification number	GUNJ0AWLD
Number of Individuals Covered	12
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $432
Total amount of fees paid to insurance company	USD $156
Other welfare benefits provided	SHORT TERM DISABLILITY
Welfare Benefit Premiums Paid to Carrier	USD $2,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $432
Insurance broker organization code?	3
Amount paid for insurance broker fees	156

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

Policy contract number

10027981001

Policy instance

Insurance contract or identification number	10027981001
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $19
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VISION - COBRA
Welfare Benefit Premiums Paid to Carrier	USD $135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19
Insurance broker organization code?	3

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

Policy contract number

10027971001

Policy instance

Insurance contract or identification number	10027971001
Number of Individuals Covered	325
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,492
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,492
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

136-421087

Policy instance

Insurance contract or identification number	136-421087
Number of Individuals Covered	185
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $14,556
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $145,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,556
Insurance broker organization code?	3

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

Policy contract number

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	251
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $4,669
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP LT CARE/GROUP IND. LTC
Welfare Benefit Premiums Paid to Carrier	USD $29,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,669
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

GLUG0AWLD

Policy instance

Insurance contract or identification number	GLUG0AWLD
Number of Individuals Covered	247
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $2,333
Total amount of fees paid to insurance company	USD $1,347
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $15,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,333
Amount paid for insurance broker fees	849
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0AWLD

Policy instance

Insurance contract or identification number	GVTL0AWLD
Number of Individuals Covered	105
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $10,358
Total amount of fees paid to insurance company	USD $5,860
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $69,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,358
Amount paid for insurance broker fees	3650
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	ADMINISTRATION

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

Policy contract number

GUG0AWLD

Policy instance

Insurance contract or identification number	GUG0AWLD
Number of Individuals Covered	247
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $5,189
Total amount of fees paid to insurance company	USD $2,964
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,189
Amount paid for insurance broker fees	1857
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD0AWLD

Policy instance

Insurance contract or identification number	GLTD0AWLD
Number of Individuals Covered	247
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $9,736
Total amount of fees paid to insurance company	USD $5,330
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,736
Amount paid for insurance broker fees	3253
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

10027971001

Policy instance

Insurance contract or identification number	10027971001
Number of Individuals Covered	307
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,045
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,045
Insurance broker organization code?	3

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

Policy contract number

10027981001

Policy instance

Insurance contract or identification number	10027981001
Number of Individuals Covered	6
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $43
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VISION - COBRA
Welfare Benefit Premiums Paid to Carrier	USD $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 $43
Insurance broker organization code?	3

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

Policy contract number

GUNJ0AWLD

Policy instance

Insurance contract or identification number	GUNJ0AWLD
Number of Individuals Covered	12
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $390
Total amount of fees paid to insurance company	USD $135
Other welfare benefits provided	SHORT TERM DISABLILITY
Welfare Benefit Premiums Paid to Carrier	USD $2,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $390
Amount paid for insurance broker fees	135
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

00001D038229

Policy instance

Insurance contract or identification number	00001D038229
Number of Individuals Covered	164
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $13,965
Total amount of fees paid to insurance company	USD $8,399
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $139,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,965
Amount paid for insurance broker fees	8399
Insurance broker organization code?	3

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

Policy contract number

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	229
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $4,998
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP LT CARE/VOL GROUP IND. LTC
Welfare Benefit Premiums Paid to Carrier	USD $32,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,998
Insurance broker organization code?	3

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

Policy contract number

GLUG0AWLD

Policy instance

Insurance contract or identification number	GLUG0AWLD
Number of Individuals Covered	223
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $2,124
Total amount of fees paid to insurance company	USD $1,379
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,124
Amount paid for insurance broker fees	794
Insurance broker organization code?	3

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

Policy contract number

GVTL0AWLD

Policy instance

Insurance contract or identification number	GVTL0AWLD
Number of Individuals Covered	95
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $9,124
Total amount of fees paid to insurance company	USD $6,225
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $60,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,124
Amount paid for insurance broker fees	3668
Insurance broker organization code?	3

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

Policy contract number

10027971001

Policy instance

Insurance contract or identification number	10027971001
Number of Individuals Covered	286
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,846
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,846

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

Policy contract number

GLTD0AWLD

Policy instance

Insurance contract or identification number	GLTD0AWLD
Number of Individuals Covered	223
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $8,132
Total amount of fees paid to insurance company	USD $5,181
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,132
Amount paid for insurance broker fees	2954
Insurance broker organization code?	3

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

Policy contract number

10027981001

Policy instance

Insurance contract or identification number	10027981001
Number of Individuals Covered	4
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VISION - COBRA
Welfare Benefit Premiums Paid to Carrier	USD $323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUNJ0AWLD

Policy instance

Insurance contract or identification number	GUNJ0AWLD
Number of Individuals Covered	13
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $337
Total amount of fees paid to insurance company	USD $140
Other welfare benefits provided	SHORT TERM DISABLILITY
Welfare Benefit Premiums Paid to Carrier	USD $2,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $337
Amount paid for insurance broker fees	120
Insurance broker organization code?	3

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

Policy contract number

GUG0AWLD

Policy instance

Insurance contract or identification number	GUG0AWLD
Number of Individuals Covered	223
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $4,642
Total amount of fees paid to insurance company	USD $3,011
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,642
Amount paid for insurance broker fees	1732
Insurance broker organization code?	3

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

Policy contract number

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	207
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $4,749
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP LT CARE/VOL GROUP IND. LTC
Welfare Benefit Premiums Paid to Carrier	USD $34,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,749
Insurance broker organization code?	3

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

Policy contract number

10027981001

Policy instance

Insurance contract or identification number	10027981001
Number of Individuals Covered	5
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $43
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VISION - COBRA
Welfare Benefit Premiums Paid to Carrier	USD $404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43

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

Policy contract number

10027971001

Policy instance

Insurance contract or identification number	10027971001
Number of Individuals Covered	240
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,578
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,578

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

Policy contract number

GUNJ0AWLD

Policy instance

Insurance contract or identification number	GUNJ0AWLD
Number of Individuals Covered	12
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $301
Total amount of fees paid to insurance company	USD $121
Other welfare benefits provided	SHORT TERM DISABLILITY
Welfare Benefit Premiums Paid to Carrier	USD $2,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $301
Amount paid for insurance broker fees	121
Insurance broker organization code?	3

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

Policy contract number

GVTL0AWLD

Policy instance

Insurance contract or identification number	GVTL0AWLD
Number of Individuals Covered	128
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $9,619
Total amount of fees paid to insurance company	USD $5,599
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $61,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,619
Amount paid for insurance broker fees	3643
Insurance broker organization code?	3

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

Policy contract number

GUG0AWLD

Policy instance

Insurance contract or identification number	GUG0AWLD
Number of Individuals Covered	208
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $4,331
Total amount of fees paid to insurance company	USD $2,657
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,331
Amount paid for insurance broker fees	1733
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

920282

Policy instance

Insurance contract or identification number	920282
Number of Individuals Covered	294
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $11,393
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,393

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

Policy contract number

GLUG0AWLD

Policy instance

Insurance contract or identification number	GLUG0AWLD
Number of Individuals Covered	208
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $1,986
Total amount of fees paid to insurance company	USD $1,129
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,986
Amount paid for insurance broker fees	705
Insurance broker organization code?	3

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

Policy contract number

GLTD0AWLD

Policy instance

Insurance contract or identification number	GLTD0AWLD
Number of Individuals Covered	208
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $7,384
Total amount of fees paid to insurance company	USD $4,459
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,384
Amount paid for insurance broker fees	2884
Insurance broker organization code?	3

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

920282

Policy instance

Insurance contract or identification number	920282
Number of Individuals Covered	293
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9,559
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $113,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,559
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	181
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $4,899
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP LT CARE/VOL GROUP IND. LTC
Welfare Benefit Premiums Paid to Carrier	USD $30,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,899
Insurance broker organization code?	3
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

GVTL0AWLD

Policy instance

Insurance contract or identification number	GVTL0AWLD
Number of Individuals Covered	95
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $9,011
Total amount of fees paid to insurance company	USD $2,500
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $60,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,011
Insurance broker organization code?	3
Amount paid for insurance broker fees	1922
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker name	PROSENTIAL BENEFITS LLC

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

Policy contract number

GLUG0AWLD

Policy instance

Insurance contract or identification number	GLUG0AWLD
Number of Individuals Covered	199
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $1,812
Total amount of fees paid to insurance company	USD $516
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,812
Insurance broker organization code?	3
Amount paid for insurance broker fees	387
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker name	PROSENTIAL BENEFITS LLC

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

Policy contract number

GUG0AWLD

Policy instance

Insurance contract or identification number	GUG0AWLD
Number of Individuals Covered	199
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $4,288
Total amount of fees paid to insurance company	USD $1,178
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,288
Insurance broker organization code?	3
Amount paid for insurance broker fees	915
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker name	PROSENTIAL BENEFITS LLC

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

Policy contract number

GLTD0AWLD

Policy instance

Insurance contract or identification number	GLTD0AWLD
Number of Individuals Covered	199
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $7,309
Total amount of fees paid to insurance company	USD $2,013
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,309
Insurance broker organization code?	3
Amount paid for insurance broker fees	1559
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker name	PROSENTIAL BENEFITS LLC

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

Policy contract number

GUNJ0AWLD

Policy instance

Insurance contract or identification number	GUNJ0AWLD
Number of Individuals Covered	11
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $296
Total amount of fees paid to insurance company	USD $27
Other welfare benefits provided	SHORT TERM DISABLILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $296
Insurance broker organization code?	3
Amount paid for insurance broker fees	27
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker name	PROSENTIAL BENEFITS LLC

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

Policy contract number

10027971001

Policy instance

Insurance contract or identification number	10027971001
Number of Individuals Covered	250
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,692
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,692
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

10027981001

Policy instance

Insurance contract or identification number	10027981001
Number of Individuals Covered	5
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $25
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	VISION - COBRA
Welfare Benefit Premiums Paid to Carrier	USD $308
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 name	FALLON BENEFITS GROUP INC

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

Policy contract number

SGD604454

Policy instance

Insurance contract or identification number	SGD604454
Insurance policy start date	2015-01-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $7,932
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,499
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

SGM604445

Policy instance

Insurance contract or identification number	SGM604445
Insurance policy start date	2015-01-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $8,870
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPP LIFE,DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $37,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,819
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

238274

Policy instance

Insurance contract or identification number	238274
Number of Individuals Covered	144
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,787
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,787
Insurance broker organization code?	3
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

SOK602956

Policy instance

Insurance contract or identification number	SOK602956
Insurance policy start date	2015-01-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $742
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $3,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $742
Insurance broker organization code?	3
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

SGD604453

Policy instance

Insurance contract or identification number	SGD604453
Insurance policy start date	2015-01-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $3,751
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,751
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

SDJ600092

Policy instance

Insurance contract or identification number	SDJ600092
Insurance policy start date	2015-01-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	STATUTORY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD600242

Policy instance

Insurance contract or identification number	NYD600242
Insurance policy start date	2015-01-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	STATUTORY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $72
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

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	193
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $4,687
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	GROUP LT CARE/GROUP IND. LTC
Welfare Benefit Premiums Paid to Carrier	USD $30,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,687
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

G000AWLD

Policy instance

Insurance contract or identification number	G000AWLD
Number of Individuals Covered	195
Insurance policy start date	2015-06-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $3,883
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,883
Insurance broker organization code?	3
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

G000AWLD

Policy instance

Insurance contract or identification number	G000AWLD
Number of Individuals Covered	195
Insurance policy start date	2015-06-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $2,314
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,314
Insurance broker organization code?	3
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

G000AWLD

Policy instance

Insurance contract or identification number	G000AWLD
Number of Individuals Covered	104
Insurance policy start date	2015-06-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $4,987
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $33,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,987
Insurance broker organization code?	3
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

G000AWLD

Policy instance

Insurance contract or identification number	G000AWLD
Number of Individuals Covered	195
Insurance policy start date	2015-06-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $1,084
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,084
Insurance broker organization code?	3
Insurance broker name	FALLON BENEFITS GROUP INC

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

Policy contract number

SGD604454

Policy instance

Insurance contract or identification number	SGD604454
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $3,210
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,210
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA,

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

Policy contract number

SGM604445

Policy instance

Insurance contract or identification number	SGM604445
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $7,092
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPP LIFE,DEP LIFE
Welfare Benefit Premiums Paid to Carrier	USD $52,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,092
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

SOK602956

Policy instance

Insurance contract or identification number	SOK602956
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $508
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $3,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $508
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	190
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $4,722
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	GROUP LT CARE/GROUP IND. LTC
Welfare Benefit Premiums Paid to Carrier	USD $33,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,391
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

SGD604453

Policy instance

Insurance contract or identification number	SGD604453
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $3,052
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,052
Additional information about fees paid to insurance broker	SALES & SERVICE
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

TM05995927

Policy instance

Insurance contract or identification number	TM05995927
Number of Individuals Covered	381
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,541
Total amount of fees paid to insurance company	USD $986
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $106,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,761
Insurance broker organization code?	3
Amount paid for insurance broker fees	986
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	FALLON BENEFITS GROUP INC

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

NYD600242

Policy instance

Insurance contract or identification number	NYD600242
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	STATUTORY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $103
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

SDJ600092

Policy instance

Insurance contract or identification number	SDJ600092
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	STATUTORY DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,941
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

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	199
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $4,827
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	GROUP LT CARE/GROUP IND. LTC
Welfare Benefit Premiums Paid to Carrier	USD $29,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,827
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

020052

Policy instance

Insurance contract or identification number	020052
Number of Individuals Covered	200
Insurance policy start date	2013-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $1,550
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,550
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

020052

Policy instance

Insurance contract or identification number	020052
Number of Individuals Covered	200
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,175
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,175
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES

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

Policy contract number

020052

Policy instance

Insurance contract or identification number	020052
Number of Individuals Covered	200
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,054
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,054
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA,

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

Policy contract number

TM05995927

Policy instance

Insurance contract or identification number	TM05995927
Number of Individuals Covered	374
Insurance policy start date	2013-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $3,400
Total amount of fees paid to insurance company	USD $1,795
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $98,363
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,400
Insurance broker organization code?	3
Amount paid for insurance broker fees	1795
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA,

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

020052

Policy instance

Insurance contract or identification number	020052
Number of Individuals Covered	120
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $5,292
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $93,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $866
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

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

Policy contract number

039504

Policy instance

Insurance contract or identification number	039504
Number of Individuals Covered	187
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $4,314
Other welfare benefits provided	GROUP & VOL. INDIV. LONG-TERM CARE
Welfare Benefit Premiums Paid to Carrier	USD $31,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,885
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

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

Policy contract number

020052

Policy instance

Insurance contract or identification number	020052
Number of Individuals Covered	188
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $14,575
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 $145,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,371
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES, INC.

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Company Name:	NEWFIELDS COMPANIES, LLC
Employer identification number (EIN):	582585034
NAIC Classification:	541330
NAIC Description:	Engineering Services

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	5653694