401k Plan data: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN plan

SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 401k Plan overview

Plan Name	SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN
Plan identification number	501

SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

SENTRY MANAGEMENT, INC. has sponsored the creation of one or more 401k plans.

Company Name: SENTRY MANAGEMENT, INC.

Employer identification number (EIN): 591625937

NAIC Classification: 531310

Additional information about SENTRY MANAGEMENT, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations

Incorporation Date: 1975-10-07

Company Identification Number: 487339

Legal Registered Office Address: 2180 W. SR 434 STE. 5000

LONGWOOD

32779

More information about SENTRY MANAGEMENT, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 ASHLEY GRAHEK 2023-07-23
501 2021-01-01 BRADLEY POMP 2022-09-23
501 2020-01-01 BRADLEY POMP 2022-09-23
501 2019-01-01 MARY TRAVER 2020-12-07
501 2018-01-01 MARY TRAVER 2019-10-11
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 DIANNE VOGHT
501 2011-01-01 DIANNE VOGHT

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	ASHLEY GRAHEK	2023-07-23
501	2021-01-01	BRADLEY POMP	2022-09-23
501	2020-01-01	BRADLEY POMP	2022-09-23
501	2019-01-01	MARY TRAVER	2020-12-07
501	2018-01-01	MARY TRAVER	2019-10-11
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	DIANNE VOGHT
501	2011-01-01	DIANNE VOGHT

Plan Statistics for SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN

401k plan membership statisitcs for SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN

Measure Date Value
2022: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 831
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 832
Number of retired or separated participants receiving benefits 2022-01-01 5
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 837
Number of employers contributing to the scheme 2022-01-01 0
2021: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 822
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 823
Number of retired or separated participants receiving benefits 2021-01-01 8
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 831
Number of employers contributing to the scheme 2021-01-01 0
2020: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 576
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 822
Number of retired or separated participants receiving benefits 2020-01-01 7
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 829
Number of employers contributing to the scheme 2020-01-01 0
2019: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 196
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 576
Number of retired or separated participants receiving benefits 2019-01-01 9
Total of all active and inactive participants 2019-01-01 585
2018: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 186
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 196
Number of retired or separated participants receiving benefits 2018-01-01 8
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 204
2017: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 265
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 186
Number of retired or separated participants receiving benefits 2017-01-01 3
Number of other retired or separated participants entitled to future benefits 2017-01-01 26
Total of all active and inactive participants 2017-01-01 215
2016: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 647
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 265
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 265
2015: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 646
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 590
Number of retired or separated participants receiving benefits 2015-01-01 18
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 608
2014: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 571
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 629
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 17
Total of all active and inactive participants 2014-01-01 646
2013: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 167
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 560
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 11
Total of all active and inactive participants 2013-01-01 571
2012: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 183
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 166
Number of retired or separated participants receiving benefits 2012-01-01 1
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 167
2011: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 189
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 181
Number of retired or separated participants receiving benefits 2011-01-01 2
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 183

Measure	Date	Value
2022: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	831
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	832
Number of retired or separated participants receiving benefits	2022-01-01	5
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	837
Number of employers contributing to the scheme	2022-01-01	0
2021: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	822
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	823
Number of retired or separated participants receiving benefits	2021-01-01	8
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	831
Number of employers contributing to the scheme	2021-01-01	0
2020: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	576
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	822
Number of retired or separated participants receiving benefits	2020-01-01	7
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	829
Number of employers contributing to the scheme	2020-01-01	0
2019: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	196
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	576
Number of retired or separated participants receiving benefits	2019-01-01	9
Total of all active and inactive participants	2019-01-01	585
2018: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	186
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	196
Number of retired or separated participants receiving benefits	2018-01-01	8
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	204
2017: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	265
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	186
Number of retired or separated participants receiving benefits	2017-01-01	3
Number of other retired or separated participants entitled to future benefits	2017-01-01	26
Total of all active and inactive participants	2017-01-01	215
2016: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	647
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	265
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	265
2015: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	646
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	590
Number of retired or separated participants receiving benefits	2015-01-01	18
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	608
2014: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	571
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	629
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	17
Total of all active and inactive participants	2014-01-01	646
2013: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	167
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	560
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	11
Total of all active and inactive participants	2013-01-01	571
2012: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	183
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	166
Number of retired or separated participants receiving benefits	2012-01-01	1
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	167
2011: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	189
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	181
Number of retired or separated participants receiving benefits	2011-01-01	2
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	183

Form 5500 Responses for SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN

2022: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH 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: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: SENTRY MANAGEMENT, INC. HEALTH BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GLUG0AKJM

Policy instance

Insurance contract or identification number	GLUG0AKJM
Number of Individuals Covered	832
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $43,718
Total amount of fees paid to insurance company	USD $27,935
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $375,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,718
Amount paid for insurance broker fees	16540
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

25165

Policy instance

Insurance contract or identification number	25165
Number of Individuals Covered	509
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $49,847
Total amount of fees paid to insurance company	USD $5,254
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $325,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,505
Amount paid for insurance broker fees	5254
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

GLUG0AKJM

Policy instance

Insurance contract or identification number	GLUG0AKJM
Number of Individuals Covered	731
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $38,911
Total amount of fees paid to insurance company	USD $15,442
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $330,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,378
Amount paid for insurance broker fees	15442
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	337
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $45,718
Total amount of fees paid to insurance company	USD $6,160
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $220,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,495
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

59392

Policy instance

Insurance contract or identification number	59392
Number of Individuals Covered	2
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $32
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	3
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $144
Total amount of fees paid to insurance company	USD $2
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

910058

Policy instance

Insurance contract or identification number	910058
Number of Individuals Covered	823
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $22,164
Total amount of fees paid to insurance company	USD $194,210
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,557,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,078
Amount paid for insurance broker fees	105799
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

910058

Policy instance

Insurance contract or identification number	910058
Number of Individuals Covered	822
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $22,703
Total amount of fees paid to insurance company	USD $214,468
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,646,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,703
Amount paid for insurance broker fees	214468
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	5
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $343
Total amount of fees paid to insurance company	USD $16
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $132
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	368
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $47,875
Total amount of fees paid to insurance company	USD $11,434
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $207,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,343
Amount paid for insurance broker fees	4414
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

59392

Policy instance

Insurance contract or identification number	59392
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $35
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35
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

GLUG0AKJM

Policy instance

Insurance contract or identification number	GLUG0AKJM
Number of Individuals Covered	778
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $40,335
Total amount of fees paid to insurance company	USD $15,376
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $343,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,335
Amount paid for insurance broker fees	15376
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	6
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,050
Total amount of fees paid to insurance company	USD $129
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $489
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

59392

Policy instance

Insurance contract or identification number	59392
Number of Individuals Covered	2
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $27
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $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 $27
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	360
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $50,058
Total amount of fees paid to insurance company	USD $10,341
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $187,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,045
Amount paid for insurance broker fees	51
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

GVTL0AKJM

Policy instance

Insurance contract or identification number	GVTL0AKJM
Number of Individuals Covered	312
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $16,360
Total amount of fees paid to insurance company	USD $3,341
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $109,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,360
Amount paid for insurance broker fees	3341
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

GUC0AKJM

Policy instance

Insurance contract or identification number	GUC0AKJM
Number of Individuals Covered	343
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $14,992
Total amount of fees paid to insurance company	USD $4,520
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $149,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,992
Amount paid for insurance broker fees	4520
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

GLUG0AKJM

Policy instance

Insurance contract or identification number	GLUG0AKJM
Number of Individuals Covered	813
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $2,644
Total amount of fees paid to insurance company	USD $694
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,644
Amount paid for insurance broker fees	694
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

GUPR0AKJM

Policy instance

Insurance contract or identification number	GUPR0AKJM
Number of Individuals Covered	148
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $6,066
Total amount of fees paid to insurance company	USD $1,853
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,066
Amount paid for insurance broker fees	1853
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

910058

Policy instance

Insurance contract or identification number	910058
Number of Individuals Covered	827
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $22,712
Total amount of fees paid to insurance company	USD $231,509
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,552,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,712
Amount paid for insurance broker fees	231509
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT AND BONUS AMOUNT
Insurance broker organization code?	3

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

Policy contract number

910058

Policy instance

Insurance contract or identification number	910058
Number of Individuals Covered	412
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $190,944
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,743,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	190944
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT AND BONUS AMOUNT
Insurance broker organization code?	3

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

Policy contract number

GUPR0AKJM

Policy instance

Insurance contract or identification number	GUPR0AKJM
Number of Individuals Covered	138
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $5,295
Total amount of fees paid to insurance company	USD $2,419
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,295
Amount paid for insurance broker fees	2419
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

774426

Policy instance

Insurance contract or identification number	774426
Number of Individuals Covered	323
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,436
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,436
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

774426

Policy instance

Insurance contract or identification number	774426
Number of Individuals Covered	254
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $11,364
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $126,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,364
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	298
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $36,256
Total amount of fees paid to insurance company	USD $10,847
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $151,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,349
Amount paid for insurance broker fees	6530
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

774426

Policy instance

Insurance contract or identification number	774426
Number of Individuals Covered	152
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,638
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,638
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

GVTL0AKJM

Policy instance

Insurance contract or identification number	GVTL0AKJM
Number of Individuals Covered	299
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $14,317
Total amount of fees paid to insurance company	USD $4,134
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,317
Amount paid for insurance broker fees	4134
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

GUC0AKJM

Policy instance

Insurance contract or identification number	GUC0AKJM
Number of Individuals Covered	320
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $12,915
Total amount of fees paid to insurance company	USD $5,297
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $129,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,915
Amount paid for insurance broker fees	5297
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

GLUG0AKJM

Policy instance

Insurance contract or identification number	GLUG0AKJM
Number of Individuals Covered	751
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $2,379
Total amount of fees paid to insurance company	USD $848
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,379
Amount paid for insurance broker fees	848
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

910058

Policy instance

Insurance contract or identification number	910058
Number of Individuals Covered	356
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $156,307
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,252,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $156,307
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

GUPR0AKJM

Policy instance

Insurance contract or identification number	GUPR0AKJM
Number of Individuals Covered	135
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $5,375
Total amount of fees paid to insurance company	USD $3,340
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,375
Amount paid for insurance broker fees	3340
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

GLUG0AKJM

Policy instance

Insurance contract or identification number	GLUG0AKJM
Number of Individuals Covered	696
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $2,261
Total amount of fees paid to insurance company	USD $1,128
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,261
Amount paid for insurance broker fees	1128
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

GUC0AKJM

Policy instance

Insurance contract or identification number	GUC0AKJM
Number of Individuals Covered	298
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $11,771
Total amount of fees paid to insurance company	USD $6,789
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $117,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,771
Amount paid for insurance broker fees	6789
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

GVTL0AKJM

Policy instance

Insurance contract or identification number	GVTL0AKJM
Number of Individuals Covered	286
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $13,780
Total amount of fees paid to insurance company	USD $5,838
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,780
Amount paid for insurance broker fees	5838
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	274
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $36,434
Total amount of fees paid to insurance company	USD $7,928
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $139,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,469
Amount paid for insurance broker fees	2806
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SUSAN HENDRICKS

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

15640 CD3265

Policy instance

Insurance contract or identification number	15640 CD3265
Number of Individuals Covered	348
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $12,007
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $142,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,007
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

774426

Policy instance

Insurance contract or identification number	774426
Number of Individuals Covered	299
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,507
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,507
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INS OFFICE OF AMERICA INC-ATLANTA

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

VS6310

Policy instance

Insurance contract or identification number	VS6310
Number of Individuals Covered	276
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,258
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,258
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

T15640,15640

Policy instance

Insurance contract or identification number	T15640,15640
Number of Individuals Covered	5
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,845
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,845
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

62630

Policy instance

Insurance contract or identification number	62630
Number of Individuals Covered	246
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $82,890
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82,890
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

GUPR0AKJM

Policy instance

Insurance contract or identification number	GUPR0AKJM
Number of Individuals Covered	152
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $5,802
Total amount of fees paid to insurance company	USD $2,606
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,802
Amount paid for insurance broker fees	2606
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

GLUG0AKJM

Policy instance

Insurance contract or identification number	GLUG0AKJM
Number of Individuals Covered	673
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $2,129
Total amount of fees paid to insurance company	USD $740
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,129
Amount paid for insurance broker fees	740
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

GUC0AKJM

Policy instance

Insurance contract or identification number	GUC0AKJM
Number of Individuals Covered	287
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $11,093
Total amount of fees paid to insurance company	USD $4,004
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $110,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,093
Amount paid for insurance broker fees	4004
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

GVTL0AKJM

Policy instance

Insurance contract or identification number	GVTL0AKJM
Number of Individuals Covered	289
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $14,585
Total amount of fees paid to insurance company	USD $3,846
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $97,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,585
Amount paid for insurance broker fees	3846
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

59392

Policy instance

Insurance contract or identification number	59392
Number of Individuals Covered	2
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $32
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	225
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $32,682
Total amount of fees paid to insurance company	USD $8,623
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $106,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,914
Amount paid for insurance broker fees	2645
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	DICE INSURANCE INC

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

15640,CD3265

Policy instance

Insurance contract or identification number	15640,CD3265
Number of Individuals Covered	304
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,048
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,048
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	613
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $1,974
Total amount of fees paid to insurance company	USD $643
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,974
Amount paid for insurance broker fees	643
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

62630

Policy instance

Insurance contract or identification number	62630
Number of Individuals Covered	167
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $55,245
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,245
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

59392

Policy instance

Insurance contract or identification number	59392
Number of Individuals Covered	2
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $51
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

VS6310

Policy instance

Insurance contract or identification number	VS6310
Number of Individuals Covered	250
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,169
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,169
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	142
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $5,791
Total amount of fees paid to insurance company	USD $2,444
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 $57,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,791
Amount paid for insurance broker fees	2444
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	265
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $12,820
Total amount of fees paid to insurance company	USD $3,482
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 $85,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,820
Amount paid for insurance broker fees	3482
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

E4214565

Policy instance

Insurance contract or identification number	E4214565
Number of Individuals Covered	179
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $47,081
Total amount of fees paid to insurance company	USD $14,543
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,060
Amount paid for insurance broker fees	3503
Insurance broker organization code?	3
Insurance broker name	KLD INSURANCE BENEFITS INC

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	228
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $8,899
Total amount of fees paid to insurance company	USD $3,351
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 $88,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,899
Amount paid for insurance broker fees	3351
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	133
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,431
Total amount of fees paid to insurance company	USD $1,931
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 $54,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,431
Amount paid for insurance broker fees	1931
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	539
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,714
Total amount of fees paid to insurance company	USD $451
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,714
Amount paid for insurance broker fees	451
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	194
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,447
Total amount of fees paid to insurance company	USD $2,202
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 $74,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,447
Amount paid for insurance broker fees	2202
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	230
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $11,606
Total amount of fees paid to insurance company	USD $2,880
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 $77,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,606
Amount paid for insurance broker fees	2880
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

59392

Policy instance

Insurance contract or identification number	59392
Number of Individuals Covered	3
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $65
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $647
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
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

VS6310

Policy instance

Insurance contract or identification number	VS6310
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

62630

Policy instance

Insurance contract or identification number	62630
Number of Individuals Covered	155
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $49,269
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,269
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

62630

Policy instance

Insurance contract or identification number	62630
Number of Individuals Covered	167
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $52,576
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,576
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD0378

Policy instance

Insurance contract or identification number	CD0378
Number of Individuals Covered	15
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $783
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $783
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

VS6310

Policy instance

Insurance contract or identification number	VS6310
Number of Individuals Covered	211
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,409
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,101
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,409
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

59392

Policy instance

Insurance contract or identification number	59392
Number of Individuals Covered	3
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $95
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $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 $95
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	219
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,786
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 $71,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,016
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	133
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,424
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 $54,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,031
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
Number of Individuals Covered	497
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,542
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,164
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

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

Policy contract number

G000AKJM

Policy instance

Insurance contract or identification number	G000AKJM
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 $6,879
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 $68,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,196
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

15640

Policy instance

Insurance contract or identification number	15640
Number of Individuals Covered	210
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,541
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $75,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,541
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA, INC.

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

26245

Policy instance

Insurance contract or identification number	26245
Number of Individuals Covered	59
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,085
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,401
Insurance broker organization code?	3
Insurance broker name	JANICE L. HUNT

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

26245

Policy instance

Insurance contract or identification number	26245
Number of Individuals Covered	69
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $5,775
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

59392

Policy instance

Insurance contract or identification number	59392
Number of Individuals Covered	4
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $97
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10093151200000

Policy instance

Insurance contract or identification number	10093151200000
Number of Individuals Covered	128
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,759
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 $47,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

62630

Policy instance

Insurance contract or identification number	62630
Number of Individuals Covered	183
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $54,298
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1009151100000

Policy instance

Insurance contract or identification number	1009151100000
Number of Individuals Covered	104
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,577
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 $45,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD0378

Policy instance

Insurance contract or identification number	CD0378
Number of Individuals Covered	15
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $351
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

15640

Policy instance

Insurance contract or identification number	15640
Number of Individuals Covered	186
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,394
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 )

Policy contract number

VS6310

Policy instance

Insurance contract or identification number	VS6310
Number of Individuals Covered	184
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,605
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

40000100006751

Policy instance

Insurance contract or identification number	40000100006751
Number of Individuals Covered	286
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,396
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 $49,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

1009151000000

Policy instance

Insurance contract or identification number	1009151000000
Number of Individuals Covered	458
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,534
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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SENTRY MANAGEMENT, INC. EMPLOYEES' PROFIT SHARING PLAN [EIN = 752348805]

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Company Name:	SENTRY MANAGEMENT, INC.
Employer identification number (EIN):	591625937
NAIC Classification:	531310

Jurisdiction of Incorporation:	Florida Department of State Division of Corporations
Incorporation Date:	1975-10-07
Company Identification Number:	487339
Legal Registered Office Address:	2180 W. SR 434 STE. 5000 LONGWOOD 32779