401k Plan data: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN plan

BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan Name	BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN
Plan identification number	501

BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

BLUE GRASS COMMUNITY ACTION AGENCY PARTNERSHIP, INC. has sponsored the creation of one or more 401k plans.

Company Name: BLUE GRASS COMMUNITY ACTION AGENCY PARTNERSHIP, INC.

Employer identification number (EIN): 610659583

NAIC Classification: 624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01
501 2021-07-01
501 2020-07-01
501 2019-07-01
501 2018-07-01
501 2017-07-01
501 2016-07-01 DEBBIE SHARP TROY ROBERTS 2018-02-15
501 2015-07-01 DEBBIE SHARP TROY ROBERTS 2017-03-22
501 2014-07-01 DEBBIE SHARP TROY ROBERTS 2016-06-16
501 2013-07-01 DEBBIE SHARP TROY ROBERTS 2015-04-13
501 2012-07-01 DEBBIE SHARP TROY ROBERTS 2014-03-17
501 2010-07-01 DAWN AUBERRY TROY ROBERTS 2012-05-04

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2022-07-01
501	2021-07-01
501	2020-07-01
501	2019-07-01
501	2018-07-01
501	2017-07-01
501	2016-07-01	DEBBIE SHARP	TROY ROBERTS	2018-02-15
501	2015-07-01	DEBBIE SHARP	TROY ROBERTS	2017-03-22
501	2014-07-01	DEBBIE SHARP	TROY ROBERTS	2016-06-16
501	2013-07-01	DEBBIE SHARP	TROY ROBERTS	2015-04-13
501	2012-07-01	DEBBIE SHARP	TROY ROBERTS	2014-03-17
501	2010-07-01	DAWN AUBERRY	TROY ROBERTS	2012-05-04

Plan Statistics for BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN

401k plan membership statisitcs for BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN

Measure Date Value
2022: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 195
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 184
Number of retired or separated participants receiving benefits 2022-07-01 1
Number of other retired or separated participants entitled to future benefits 2022-07-01 0
Total of all active and inactive participants 2022-07-01 185
2021: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 242
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 195
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 195
2020: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 324
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 242
Number of retired or separated participants receiving benefits 2020-07-01 0
Number of other retired or separated participants entitled to future benefits 2020-07-01 0
Total of all active and inactive participants 2020-07-01 242
2019: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 365
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 193
Number of retired or separated participants receiving benefits 2019-07-01 131
Number of other retired or separated participants entitled to future benefits 2019-07-01 0
Total of all active and inactive participants 2019-07-01 324
2018: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 370
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 258
Total of all active and inactive participants 2018-07-01 258
2017: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 344
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 255
Total of all active and inactive participants 2017-07-01 255
2016: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 235
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 344
Total of all active and inactive participants 2016-07-01 344
2015: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 149
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 235
Total of all active and inactive participants 2015-07-01 235
2014: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 149
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 149
Total of all active and inactive participants 2014-07-01 149
2013: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 156
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 149
Total of all active and inactive participants 2013-07-01 149
2012: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 167
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 156
Total of all active and inactive participants 2012-07-01 156
2010: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 102
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 0
Total of all active and inactive participants 2010-07-01 0
Total participants 2010-07-01 0

Measure	Date	Value
2022: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	195
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	184
Number of retired or separated participants receiving benefits	2022-07-01	1
Number of other retired or separated participants entitled to future benefits	2022-07-01	0
Total of all active and inactive participants	2022-07-01	185
2021: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	242
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	195
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	195
2020: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	324
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	242
Number of retired or separated participants receiving benefits	2020-07-01	0
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	242
2019: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	365
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	193
Number of retired or separated participants receiving benefits	2019-07-01	131
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	324
2018: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	370
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	258
Total of all active and inactive participants	2018-07-01	258
2017: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	344
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	255
Total of all active and inactive participants	2017-07-01	255
2016: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	235
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	344
Total of all active and inactive participants	2016-07-01	344
2015: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	149
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	235
Total of all active and inactive participants	2015-07-01	235
2014: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	149
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	149
Total of all active and inactive participants	2014-07-01	149
2013: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	156
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	149
Total of all active and inactive participants	2013-07-01	149
2012: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	167
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	156
Total of all active and inactive participants	2012-07-01	156
2010: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	102
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	0
Total of all active and inactive participants	2010-07-01	0
Total participants	2010-07-01	0

Form 5500 Responses for BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN

2022: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2021: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2015: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2010: BLUE GRASS COMMUNITY ACTION FLEXIBLE BENEFITS PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Submission has been amended	No
2010-07-01	This submission is the final filing	No
2010-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-07-01	Plan is a collectively bargained plan	No
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

L04803

Policy instance

Insurance contract or identification number	L04803
Number of Individuals Covered	184
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $23,658
Total amount of fees paid to insurance company	USD $5,138
Health Insurance Welfare Benefit	Yes
Vision 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 $23,658
Amount paid for insurance broker fees	5138

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CM10001288

Policy instance

Insurance contract or identification number	CM10001288
Number of Individuals Covered	199
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,614
Total amount of fees paid to insurance company	USD $2,188
Life 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 $6,614
Amount paid for insurance broker fees	2188

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0711900

Policy instance

Insurance contract or identification number	0711900
Number of Individuals Covered	305
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,276
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,276
Amount paid for insurance broker fees	0

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

47849

Policy instance

Insurance contract or identification number	47849
Number of Individuals Covered	6
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $49
Total amount of fees paid to insurance company	USD $0
Life 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 $28

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	37
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,940
Total amount of fees paid to insurance company	USD $254
Life 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 $3,834
Amount paid for insurance broker fees	0

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	32
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,926
Total amount of fees paid to insurance company	USD $195
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,578
Amount paid for insurance broker fees	171

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

47849

Policy instance

Insurance contract or identification number	47849
Number of Individuals Covered	6
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $52
Total amount of fees paid to insurance company	USD $0
Life 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 $30

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

Policy contract number

00557070

Policy instance

Insurance contract or identification number	00557070
Number of Individuals Covered	196
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,708
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, OPTIONAL AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,708
Amount paid for insurance broker fees	0

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

Policy contract number

0916544

Policy instance

Insurance contract or identification number	0916544
Number of Individuals Covered	81
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $17,680
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 $11,766

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0711900

Policy instance

Insurance contract or identification number	0711900
Number of Individuals Covered	291
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,558
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,558

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

71190V

Policy instance

Insurance contract or identification number	71190V
Number of Individuals Covered	394
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $982
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $982

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

Policy contract number

0916544

Policy instance

Insurance contract or identification number	0916544
Number of Individuals Covered	84
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

0711900

Policy instance

Insurance contract or identification number	0711900
Number of Individuals Covered	293
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,594
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,594

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

71190V

Policy instance

Insurance contract or identification number	71190V
Number of Individuals Covered	387
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $608
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $608

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	31
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,863
Total amount of fees paid to insurance company	USD $106
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,933
Amount paid for insurance broker fees	53

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

47849

Policy instance

Insurance contract or identification number	47849
Number of Individuals Covered	7
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $52
Total amount of fees paid to insurance company	USD $0
Life 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 $30

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

Policy contract number

00557070

Policy instance

Insurance contract or identification number	00557070
Number of Individuals Covered	183
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,767
Total amount of fees paid to insurance company	USD $2,019
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, OPTIONAL AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,767
Amount paid for insurance broker fees	2019

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	24
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $679
Total amount of fees paid to insurance company	USD $6
Life 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 $429
Amount paid for insurance broker fees	0

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

47849

Policy instance

Insurance contract or identification number	47849
Number of Individuals Covered	8
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $55
Total amount of fees paid to insurance company	USD $0
Life 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 $31

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

Policy contract number

00557070

Policy instance

Insurance contract or identification number	00557070
Number of Individuals Covered	193
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,486
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, OPTIONAL AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,486

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

Policy contract number

0916544

Policy instance

Insurance contract or identification number	0916544
Number of Individuals Covered	106
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $12,854
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 $12,854

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	29
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $885
Total amount of fees paid to insurance company	USD $28
Life 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 $553
Amount paid for insurance broker fees	21

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00248620

Policy instance

Insurance contract or identification number	00248620
Number of Individuals Covered	402
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $18,165
Total amount of fees paid to insurance company	USD $129
Health Insurance Welfare Benefit	Yes
Vision 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 $13,293
Amount paid for insurance broker fees	129

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

528547

Policy instance

Insurance contract or identification number	528547
Number of Individuals Covered	147
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,321
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,321

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

47849

Policy instance

Insurance contract or identification number	47849
Number of Individuals Covered	9
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $58
Total amount of fees paid to insurance company	USD $0
Life 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 $33

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00248620

Policy instance

Insurance contract or identification number	00248620
Number of Individuals Covered	166
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,719
Total amount of fees paid to insurance company	USD $652
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,306
Amount paid for insurance broker fees	652

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

47849

Policy instance

Insurance contract or identification number	47849
Number of Individuals Covered	10
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-30
Total amount of commissions paid to insurance broker	USD $61
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	35
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,110
Total amount of fees paid to insurance company	USD $96
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

TM05923772

Policy instance

Insurance contract or identification number	TM05923772
Number of Individuals Covered	305
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,657
Total amount of fees paid to insurance company	USD $1,181
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00248620

Policy instance

Insurance contract or identification number	00248620
Number of Individuals Covered	469
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $21,706
Total amount of fees paid to insurance company	USD $4,866
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00248620

Policy instance

Insurance contract or identification number	00248620
Number of Individuals Covered	190
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,182
Total amount of fees paid to insurance company	USD $718
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	32
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,251
Total amount of fees paid to insurance company	USD $998
Life 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 $2,158
Amount paid for insurance broker fees	499
Insurance broker name	BART GAUNT

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

47849

Policy instance

Insurance contract or identification number	47849
Number of Individuals Covered	14
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $93
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	50
Insurance broker name	ROBERT BAYS

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ENT58

Policy instance

Insurance contract or identification number	ENT58
Number of Individuals Covered	43
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,610
Total amount of fees paid to insurance company	USD $253
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 $1,111
Amount paid for insurance broker fees	111
Insurance broker name	RUEANN EMERSON

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

Policy contract number

000000536355

Policy instance

Insurance contract or identification number	000000536355
Number of Individuals Covered	8
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $304
Total amount of fees paid to insurance company	USD $0
Life 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 $304
Insurance broker name	PHIL BROWN INSURANCE AGENCY

HUMANA INSURANCE COMPANY OF KENTUCKY INC (National Association of Insurance Commissioners NAIC id number: 60219 )

Policy contract number

738896

Policy instance

Insurance contract or identification number	738896
Number of Individuals Covered	196
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,499
Total amount of fees paid to insurance company	USD $0
Life 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 $3,499
Insurance broker name	J SMITH LANIER & CO - WIS LLC

HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 )

Policy contract number

738896

Policy instance

Insurance contract or identification number	738896
Number of Individuals Covered	77
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $28,712
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 $28,712
Insurance broker name	J SMITH LANIER & CO - WIS LLC

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 54739 )

Policy contract number

738896

Policy instance

Insurance contract or identification number	738896
Number of Individuals Covered	180
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,504
Total amount of fees paid to insurance company	USD $0
Vision 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 $2,504
Insurance broker name	J SMITH LANIER & CO - WIS LLC

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

Policy contract number

TM05923772

Policy instance

Insurance contract or identification number	TM05923772
Number of Individuals Covered	264
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,860
Total amount of fees paid to insurance company	USD $19
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,860
Amount paid for insurance broker fees	19
Insurance broker name	J SMITH LANIER & CO - WIS LLC

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	13
Insurance policy start date	2014-07-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,100
Total amount of fees paid to insurance company	USD $15
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $468
Amount paid for insurance broker fees	0
Insurance broker name	BART GAUNT

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

M00060

Policy instance

Insurance contract or identification number	M00060
Number of Individuals Covered	216
Insurance policy start date	2014-07-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,152
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $576
Insurance broker name	PHIL BROWN INSURANCE AGENCY

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

Policy contract number

G-501B

Policy instance

Insurance contract or identification number	G-501B
Number of Individuals Covered	8
Insurance policy start date	2014-07-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,845
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 $1,190
Insurance broker name	KENTUCKY CHAMBER OF COMMERCE

BOSTON MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61476 )

Policy contract number

47849

Policy instance

Insurance contract or identification number	47849
Number of Individuals Covered	15
Insurance policy start date	2014-07-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $101
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
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
Insurance broker name	ROBERT BAYS/ FARMERS CAPITAL INSURA

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

ENT58

Policy instance

Insurance contract or identification number	ENT58
Number of Individuals Covered	76
Insurance policy start date	2014-07-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,106
Total amount of fees paid to insurance company	USD $176
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 $1,261
Amount paid for insurance broker fees	66
Insurance broker name	RUEANN EMERSON

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00065007

Policy instance

Insurance contract or identification number	00065007
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,052
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,052
Insurance broker name	PHIL BROWN INSURANCE AGENCY

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00065007

Policy instance

Insurance contract or identification number	00065007
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $15,464
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,732
Insurance broker name	PHIL BROWN INSURANCE AGENCY

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

Policy contract number

000000536355

Policy instance

Insurance contract or identification number	000000536355
Insurance policy start date	2014-07-01
Insurance policy end date	2014-12-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

G-501B

Policy instance

Insurance contract or identification number	G-501B
Number of Individuals Covered	8
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $6,706
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 $4,327
Insurance broker name	KENTUCKY CHAMBER OF COMMERCE

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	6
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $312
Total amount of fees paid to insurance company	USD $5
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $194
Amount paid for insurance broker fees	4
Insurance broker name	MARK HOLLAND

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

Policy contract number

000000536355

Policy instance

Insurance contract or identification number	000000536355
Insurance policy start date	2013-07-01
Insurance policy end date	2014-07-01
Total amount of commissions paid to insurance broker	USD $398
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $398
Insurance broker name	PHIL BROWN INSURANCE AGENCY

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

Policy contract number

E7007388

Policy instance

Insurance contract or identification number	E7007388
Number of Individuals Covered	5
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
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
Life 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 $39
Amount paid for insurance broker fees	0
Insurance broker name	MARK HOLLAND

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

Policy contract number

000000536355

Policy instance

Insurance contract or identification number	000000536355
Number of Individuals Covered	12
Insurance policy start date	2012-07-01
Insurance policy end date	2013-07-01
Total amount of commissions paid to insurance broker	USD $408
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $408
Insurance broker name	PHIL BROWN INSURANCE AGENCY

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

Policy contract number

G-501B

Policy instance

Insurance contract or identification number	G-501B
Number of Individuals Covered	26
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $7,208
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 $4,651
Insurance broker name	KENTUCKY CHAMBER OF COMMERCE

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00065007

Policy instance

Insurance contract or identification number	00065007
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $22,740
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
Vision 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 $11,370
Insurance broker name	COMMUNITY ACTION KENTUCKY, INC

DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 )

Policy contract number

M00060-0004

Policy instance

Insurance contract or identification number	M00060-0004
Number of Individuals Covered	250
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $2,150
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,075
Insurance broker name	PHIL BROWN INSURANCE AGENCY

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

00065007

Policy instance

Insurance contract or identification number	00065007
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,774
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,774
Insurance broker organization code?	3
Insurance broker name	PHIL BROWN INSURANCE AGENCY

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00065007

Policy instance

Insurance contract or identification number	00065007
Number of Individuals Covered	120
Total amount of commissions paid to insurance broker	USD $27,501
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

536355

Policy instance

Insurance contract or identification number	536355
Number of Individuals Covered	14
Total amount of commissions paid to insurance broker	USD $688
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00065007

Policy instance

Insurance contract or identification number	00065007
Number of Individuals Covered	141
Total amount of commissions paid to insurance broker	USD $2,026
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	BLUE GRASS COMMUNITY ACTION AGENCY PARTNERSHIP, INC.
Employer identification number (EIN):	610659583
NAIC Classification:	624100
NAIC Description:	Individual and Family Services