401k Plan data: THE FATHER'S TABLE HEALTH AND WELFARE PLAN plan

THE FATHER'S TABLE HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	THE FATHER'S TABLE HEALTH AND WELFARE PLAN
Plan identification number	501

THE FATHER'S TABLE HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

THE FATHER'S TABLE, INC. has sponsored the creation of one or more 401k plans.

Company Name: THE FATHER'S TABLE, INC.

Employer identification number (EIN): 593578064

NAIC Classification: 722300
NAIC Description: Special Food Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE FATHER'S TABLE HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-06-01 LUIZ SILVA
501 2021-06-01 LUIZ SILVA 2023-03-14
501 2020-06-01 LUIZ SILVA 2021-12-07
501 2019-06-01 LUIZ SILVA 2020-11-30
501 2018-06-01 LUIZ SILVA 2019-11-12
501 2017-06-01
501 2016-06-01
501 2015-06-01
501 2014-06-01
501 2013-06-01
501 2012-06-01 DENISE CLARK
501 2011-06-01 DENISE CLARK DENISE CLARK 2013-03-12
501 2009-06-01 DENISE CLARK DENISE CLARK 2011-03-14

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-06-01	LUIZ SILVA
501	2021-06-01	LUIZ SILVA	2023-03-14
501	2020-06-01	LUIZ SILVA	2021-12-07
501	2019-06-01	LUIZ SILVA	2020-11-30
501	2018-06-01	LUIZ SILVA	2019-11-12
501	2017-06-01
501	2016-06-01
501	2015-06-01
501	2014-06-01
501	2013-06-01
501	2012-06-01	DENISE CLARK
501	2011-06-01	DENISE CLARK		DENISE CLARK	2013-03-12
501	2009-06-01	DENISE CLARK		DENISE CLARK	2011-03-14

Plan Statistics for THE FATHER'S TABLE HEALTH AND WELFARE PLAN

401k plan membership statisitcs for THE FATHER'S TABLE HEALTH AND WELFARE PLAN

Measure Date Value
2022: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 416
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 370
Total of all active and inactive participants 2022-06-01 370
2021: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-06-01 413
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 416
Total of all active and inactive participants 2021-06-01 416
2020: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 398
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 413
Number of retired or separated participants receiving benefits 2020-06-01 0
Number of other retired or separated participants entitled to future benefits 2020-06-01 0
Total of all active and inactive participants 2020-06-01 413
2019: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 259
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 398
Number of retired or separated participants receiving benefits 2019-06-01 0
Number of other retired or separated participants entitled to future benefits 2019-06-01 0
Total of all active and inactive participants 2019-06-01 398
2018: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 355
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 259
Number of retired or separated participants receiving benefits 2018-06-01 0
Number of other retired or separated participants entitled to future benefits 2018-06-01 0
Total of all active and inactive participants 2018-06-01 259
2017: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 303
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 355
Number of retired or separated participants receiving benefits 2017-06-01 0
Number of other retired or separated participants entitled to future benefits 2017-06-01 0
Total of all active and inactive participants 2017-06-01 355
2016: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-06-01 301
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 303
Number of retired or separated participants receiving benefits 2016-06-01 0
Number of other retired or separated participants entitled to future benefits 2016-06-01 0
Total of all active and inactive participants 2016-06-01 303
2015: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-06-01 230
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 301
Number of retired or separated participants receiving benefits 2015-06-01 0
Number of other retired or separated participants entitled to future benefits 2015-06-01 0
Total of all active and inactive participants 2015-06-01 301
2014: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-06-01 366
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 230
Number of retired or separated participants receiving benefits 2014-06-01 0
Number of other retired or separated participants entitled to future benefits 2014-06-01 0
Total of all active and inactive participants 2014-06-01 230
2013: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-06-01 223
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 366
Total of all active and inactive participants 2013-06-01 366
2012: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-06-01 366
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 223
Total of all active and inactive participants 2012-06-01 223
2011: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-06-01 366
Total number of active participants reported on line 7a of the Form 5500 2011-06-01 366
Total of all active and inactive participants 2011-06-01 366
2009: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-06-01 151
Total number of active participants reported on line 7a of the Form 5500 2009-06-01 204
Number of retired or separated participants receiving benefits 2009-06-01 2
Total of all active and inactive participants 2009-06-01 206

Measure	Date	Value
2022: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	416
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	370
Total of all active and inactive participants	2022-06-01	370
2021: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-06-01	413
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	416
Total of all active and inactive participants	2021-06-01	416
2020: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	398
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	413
Number of retired or separated participants receiving benefits	2020-06-01	0
Number of other retired or separated participants entitled to future benefits	2020-06-01	0
Total of all active and inactive participants	2020-06-01	413
2019: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	259
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	398
Number of retired or separated participants receiving benefits	2019-06-01	0
Number of other retired or separated participants entitled to future benefits	2019-06-01	0
Total of all active and inactive participants	2019-06-01	398
2018: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	355
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	259
Number of retired or separated participants receiving benefits	2018-06-01	0
Number of other retired or separated participants entitled to future benefits	2018-06-01	0
Total of all active and inactive participants	2018-06-01	259
2017: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	303
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	355
Number of retired or separated participants receiving benefits	2017-06-01	0
Number of other retired or separated participants entitled to future benefits	2017-06-01	0
Total of all active and inactive participants	2017-06-01	355
2016: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	301
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	303
Number of retired or separated participants receiving benefits	2016-06-01	0
Number of other retired or separated participants entitled to future benefits	2016-06-01	0
Total of all active and inactive participants	2016-06-01	303
2015: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	230
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	301
Number of retired or separated participants receiving benefits	2015-06-01	0
Number of other retired or separated participants entitled to future benefits	2015-06-01	0
Total of all active and inactive participants	2015-06-01	301
2014: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	366
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	230
Number of retired or separated participants receiving benefits	2014-06-01	0
Number of other retired or separated participants entitled to future benefits	2014-06-01	0
Total of all active and inactive participants	2014-06-01	230
2013: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-06-01	223
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	366
Total of all active and inactive participants	2013-06-01	366
2012: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-06-01	366
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	223
Total of all active and inactive participants	2012-06-01	223
2011: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-06-01	366
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	366
Total of all active and inactive participants	2011-06-01	366
2009: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-06-01	151
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	204
Number of retired or separated participants receiving benefits	2009-06-01	2
Total of all active and inactive participants	2009-06-01	206

Form 5500 Responses for THE FATHER'S TABLE HEALTH AND WELFARE PLAN

2022: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2021: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2020: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2019: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2018: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2017: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2016: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2015: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2014: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2013: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2012: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2011: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes
2009: THE FATHER'S TABLE HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	This submission is the final filing	No
2009-06-01	Plan funding arrangement – Insurance	Yes
2009-06-01	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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	272
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $12,463
Total amount of fees paid to insurance company	USD $2,185
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,463
Amount paid for insurance broker fees	2185
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

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	470
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $2,742
Total amount of fees paid to insurance company	USD $573
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,742
Amount paid for insurance broker fees	573
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	71
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $3,959
Total amount of fees paid to insurance company	USD $1,182
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,959
Amount paid for insurance broker fees	1182
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	70
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $2,035
Total amount of fees paid to insurance company	USD $284
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,035
Amount paid for insurance broker fees	284
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

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	387
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $20,256
Total amount of fees paid to insurance company	USD $8,581
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,256
Amount paid for insurance broker fees	8581
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

E4133542

Policy instance

Insurance contract or identification number	E4133542
Number of Individuals Covered	308
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $42,524
Total amount of fees paid to insurance company	USD $10,051
Other welfare benefits provided	ACCIDENT CANCER CRITICAL ILL HOSP
Welfare Benefit Premiums Paid to Carrier	USD $257,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,203
Amount paid for insurance broker fees	3118
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	330
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $23,560
Total amount of fees paid to insurance company	USD $6,957
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $157,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,560
Amount paid for insurance broker fees	6957
Insurance broker organization code?	3

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

Policy contract number

3345032

Policy instance

Insurance contract or identification number	3345032
Number of Individuals Covered	507
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $898,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	638
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $3,098
Total amount of fees paid to insurance company	USD $1,245
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,761,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,098
Amount paid for insurance broker fees	1245
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	76
Insurance policy start date	2021-06-01
Insurance policy end date	2022-06-01
Total amount of commissions paid to insurance broker	USD $3,739
Total amount of fees paid to insurance company	USD $1,137
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,739
Amount paid for insurance broker fees	1137
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	387
Insurance policy start date	2021-06-01
Insurance policy end date	2022-06-01
Total amount of commissions paid to insurance broker	USD $19,609
Total amount of fees paid to insurance company	USD $5,515
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $130,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,609
Amount paid for insurance broker fees	5515
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

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	410
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $21,597
Total amount of fees paid to insurance company	USD $10,127
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $215,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,597
Amount paid for insurance broker fees	10127
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

E4133542

Policy instance

Insurance contract or identification number	E4133542
Number of Individuals Covered	409
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $69,867
Total amount of fees paid to insurance company	USD $13,618
Other welfare benefits provided	ACCIDENT CANCER CRITICAL ILL HOSP
Welfare Benefit Premiums Paid to Carrier	USD $303,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,646
Amount paid for insurance broker fees	615
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

302887

Policy instance

Insurance contract or identification number	302887
Number of Individuals Covered	305
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $14,248
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $108,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,248
Insurance broker organization code?	3

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	780
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $3,212
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,966,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,212
Insurance broker organization code?	3

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	72
Insurance policy start date	2020-06-01
Insurance policy end date	2021-06-01
Total amount of commissions paid to insurance broker	USD $3,679
Total amount of fees paid to insurance company	USD $968
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,679
Amount paid for insurance broker fees	968
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	335
Insurance policy start date	2020-06-01
Insurance policy end date	2021-06-01
Total amount of commissions paid to insurance broker	USD $18,273
Total amount of fees paid to insurance company	USD $5,214
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $121,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,273
Amount paid for insurance broker fees	5214
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

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	395
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $22,481
Total amount of fees paid to insurance company	USD $11,108
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $224,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,481
Amount paid for insurance broker fees	11108
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

E4133542

Policy instance

Insurance contract or identification number	E4133542
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $75,896
Total amount of fees paid to insurance company	USD $22,446
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENT CANCER CRITICAL ILL HOSP
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,526
Amount paid for insurance broker fees	8630
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

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	676
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $3,051
Total amount of fees paid to insurance company	USD $214
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,845,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,051
Amount paid for insurance broker fees	214
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	66
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $2,688
Total amount of fees paid to insurance company	USD $827
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,688
Amount paid for insurance broker fees	827
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	337
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $14,872
Total amount of fees paid to insurance company	USD $4,519
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,872
Amount paid for insurance broker fees	4519
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

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	417
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $22,214
Total amount of fees paid to insurance company	USD $8,301
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $222,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,214
Amount paid for insurance broker fees	8301
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

E4133542

Policy instance

Insurance contract or identification number	E4133542
Number of Individuals Covered	406
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $66,615
Total amount of fees paid to insurance company	USD $13,266
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD CANCER CRITICAL ILLNESS HOSPITA
Welfare Benefit Premiums Paid to Carrier	USD $266,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,171
Insurance broker organization code?	3
Amount paid for insurance broker fees	6328
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	647
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $2,683
Total amount of fees paid to insurance company	USD $785
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,466,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,683
Amount paid for insurance broker fees	785
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	55
Insurance policy start date	2018-06-01
Insurance policy end date	2019-06-01
Total amount of commissions paid to insurance broker	USD $2,409
Total amount of fees paid to insurance company	USD $515
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,063
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
Amount paid for insurance broker fees	515
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	297
Insurance policy start date	2019-06-01
Insurance policy end date	2019-06-01
Total amount of commissions paid to insurance broker	USD $13,671
Total amount of fees paid to insurance company	USD $2,893
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,671
Amount paid for insurance broker fees	2893
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

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	402
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $20,989
Total amount of fees paid to insurance company	USD $9,365
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $209,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,989
Amount paid for insurance broker fees	9365
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

E4133542

Policy instance

Insurance contract or identification number	E4133542
Number of Individuals Covered	367
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $59,822
Total amount of fees paid to insurance company	USD $19,519
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD CANCER CRITICAL ILLNESS HOSPITA
Welfare Benefit Premiums Paid to Carrier	USD $222,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,688
Amount paid for insurance broker fees	8694
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

E4133542

Policy instance

Insurance contract or identification number	E4133542
Number of Individuals Covered	355
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $56,967
Total amount of fees paid to insurance company	USD $11,543
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD CANCER CRITICAL ILLNESS HOSPITA
Welfare Benefit Premiums Paid to Carrier	USD $193,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,600
Amount paid for insurance broker fees	3902
Insurance broker organization code?	3
Insurance broker name	EC BENEFITS INC

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

Policy contract number

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	366
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $19,522
Total amount of fees paid to insurance company	USD $7,518
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $195,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,522
Amount paid for insurance broker fees	7518
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	309
Insurance policy start date	2018-06-01
Insurance policy end date	2018-06-01
Total amount of commissions paid to insurance broker	USD $13,139
Total amount of fees paid to insurance company	USD $3,582
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $87,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,139
Amount paid for insurance broker fees	3582
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	58
Insurance policy start date	2017-06-01
Insurance policy end date	2018-06-01
Total amount of commissions paid to insurance broker	USD $2,274
Total amount of fees paid to insurance company	USD $676
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,274
Amount paid for insurance broker fees	676
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	631
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $2,727
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,419,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,727
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	533
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $2,040
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,722,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,040
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	52
Insurance policy start date	2015-06-01
Insurance policy end date	2016-06-01
Total amount of commissions paid to insurance broker	USD $1,859
Total amount of fees paid to insurance company	USD $551
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,859
Amount paid for insurance broker fees	551
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	288
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $15,384
Total amount of fees paid to insurance company	USD $6,607
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $153,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,384
Amount paid for insurance broker fees	6607
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

E4133542

Policy instance

Insurance contract or identification number	E4133542
Number of Individuals Covered	301
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $28,256
Total amount of fees paid to insurance company	USD $5,876
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD CANCER CRITICAL ILLNESS HOSPITA
Welfare Benefit Premiums Paid to Carrier	USD $110,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,490
Amount paid for insurance broker fees	2256
Insurance broker organization code?	3
Insurance broker name	SALATHIEL MALDONADO

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	238
Insurance policy start date	2016-06-01
Insurance policy end date	2016-06-01
Total amount of commissions paid to insurance broker	USD $7,549
Total amount of fees paid to insurance company	USD $2,191
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,549
Amount paid for insurance broker fees	2191
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	366
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $23,208
Total amount of fees paid to insurance company	USD $-43,599
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 $2,266,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $23,208
Amount paid for insurance broker fees	-43599
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	50
Insurance policy start date	2014-06-01
Insurance policy end date	2015-06-01
Total amount of commissions paid to insurance broker	USD $1,856
Total amount of fees paid to insurance company	USD $560
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 $12,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,856
Amount paid for insurance broker fees	560
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	212
Insurance policy start date	2015-06-01
Insurance policy end date	2015-06-01
Total amount of commissions paid to insurance broker	USD $6,933
Total amount of fees paid to insurance company	USD $2,019
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 $46,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,933
Amount paid for insurance broker fees	2019
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	261
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $14,419
Total amount of fees paid to insurance company	USD $7,425
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 $144,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,419
Amount paid for insurance broker fees	7425
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

E4133542

Policy instance

Insurance contract or identification number	E4133542
Number of Individuals Covered	230
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $31,337
Total amount of fees paid to insurance company	USD $8,541
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	ADD CANCER CRITICAL ILLNESS HOSPITA
Welfare Benefit Premiums Paid to Carrier	USD $92,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,446
Amount paid for insurance broker fees	2534
Insurance broker organization code?	3
Insurance broker name	EC BENEFITS INC

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	194
Insurance policy start date	2014-06-01
Insurance policy end date	2014-06-01
Total amount of commissions paid to insurance broker	USD $6,603
Total amount of fees paid to insurance company	USD $1,807
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 $44,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,603
Amount paid for insurance broker fees	1807
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	218
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $14,075
Total amount of fees paid to insurance company	USD $5,113
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 $140,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,075
Amount paid for insurance broker fees	5113
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

E4133542

Policy instance

Insurance contract or identification number	E4133542
Number of Individuals Covered	191
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $39,290
Total amount of fees paid to insurance company	USD $15,840
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	ADD CANCER CRITICAL ILLNESS HOSPITA
Welfare Benefit Premiums Paid to Carrier	USD $64,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,843
Amount paid for insurance broker fees	2664
Insurance broker organization code?	3
Insurance broker name	EC BENEFITS INC

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	50
Insurance policy start date	2013-06-01
Insurance policy end date	2014-06-01
Total amount of commissions paid to insurance broker	USD $1,841
Total amount of fees paid to insurance company	USD $522
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 $12,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,841
Amount paid for insurance broker fees	522
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	366
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $-21,464
Total amount of fees paid to insurance company	USD $46,278
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,868,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,360
Amount paid for insurance broker fees	22233
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN OF FLORIDA INC

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

Policy contract number

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	178
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $10,345
Total amount of fees paid to insurance company	USD $5,693
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 $101,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,248
Amount paid for insurance broker fees	5693
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN INC

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

Policy contract number

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Insurance policy start date	2013-06-01
Insurance policy end date	2013-06-01
Total amount of commissions paid to insurance broker	USD $5,379
Total amount of fees paid to insurance company	USD $2,743
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 $35,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,516
Amount paid for insurance broker fees	2743
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

GLTD0AJ33

Policy instance

Insurance contract or identification number	GLTD0AJ33
Insurance policy start date	2012-06-01
Insurance policy end date	2013-06-01
Total amount of commissions paid to insurance broker	USD $1,650
Total amount of fees paid to insurance company	USD $716
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 $10,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,388
Amount paid for insurance broker fees	716
Insurance broker organization code?	3
Insurance broker name	INSURANCE OFFICE OF AMERICA

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

Policy contract number

0716507

Policy instance

Insurance contract or identification number	0716507
Number of Individuals Covered	195
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $76,146
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,522,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $76,146
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN INC

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

Policy contract number

302887

Policy instance

Insurance contract or identification number	302887
Number of Individuals Covered	100
Insurance policy start date	2011-05-31
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $5,951
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $39,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00467875

Policy instance

Insurance contract or identification number	00467875
Number of Individuals Covered	177
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $12,204
Total amount of fees paid to insurance company	USD $4,427
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 $113,523
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	154
Insurance policy start date	2012-06-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $4,905
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,702
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

G000AJ33

Policy instance

Insurance contract or identification number	G000AJ33
Number of Individuals Covered	50
Insurance policy start date	2011-06-01
Insurance policy end date	2012-06-01
Total amount of commissions paid to insurance broker	USD $1,818
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 $11,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	366
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $74,200
Total amount of fees paid to insurance company	USD $3,546
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,483,990
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

000010103574

Policy instance

Insurance contract or identification number	000010103574
Number of Individuals Covered	51
Insurance policy start date	2010-05-31
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $1,464
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 $9,759
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

000010103575

Policy instance

Insurance contract or identification number	000010103575
Number of Individuals Covered	132
Insurance policy start date	2010-05-31
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $3,548
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 $23,655
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

000400001000

Policy instance

Insurance contract or identification number	000400001000
Number of Individuals Covered	91
Insurance policy start date	2010-05-31
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $3,953
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 $26,354
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

000010103573

Policy instance

Insurance contract or identification number	000010103573
Number of Individuals Covered	51
Insurance policy start date	2010-05-31
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $1,041
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,942
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

00001D018143

Policy instance

Insurance contract or identification number	00001D018143
Number of Individuals Covered	170
Insurance policy start date	2010-05-31
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $9,870
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 $98,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

716507

Policy instance

Insurance contract or identification number	716507
Number of Individuals Covered	366
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $74,508
Total amount of fees paid to insurance company	USD $125
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,490,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

THE FATHER'S HOUSE OC 401(K) PLAN [EIN = 822803812]

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Company Name:	THE FATHER'S TABLE, INC.
Employer identification number (EIN):	593578064
NAIC Classification:	722300
NAIC Description:	Special Food Services