401k Plan data: CO-OP HEALTH & WELFARE PLAN AND TRUST plan

CO-OP HEALTH & WELFARE PLAN AND TRUST 401k Plan overview

Plan Name	CO-OP HEALTH & WELFARE PLAN AND TRUST
Plan identification number	506

CO-OP HEALTH & WELFARE PLAN AND TRUST 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 Other welfare benefit cover

401k Sponsoring company profile

TENNESSEE FARMERS COOPERATIVE has sponsored the creation of one or more 401k plans.

Company Name: TENNESSEE FARMERS COOPERATIVE

Employer identification number (EIN): 620435104

NAIC Classification: 423990
NAIC Description: Other Miscellaneous Durable Goods Merchant Wholesalers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CO-OP HEALTH & WELFARE PLAN AND TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2021-07-01 JOHN CAIN 2023-04-14
506 2020-07-01 JOHN CAIN 2022-04-15
506 2019-07-01 JOHN E CAIN 2021-05-12
506 2019-07-01 JOHN E CAIN 2021-04-15
506 2018-07-01 JOHN E CAIN 2020-04-14
506 2017-07-01 JOHN E CAIN 2019-04-15
506 2016-07-01
506 2015-07-01
506 2014-07-01
506 2013-07-01 JOHN E CAIN
506 2012-07-01 JOHN E CAIN
506 2011-07-01 JOHN E CAIN
506 2010-07-01 JOHN E CAIN
506 2009-07-01 JOHN E CAIN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
506	2021-07-01	JOHN CAIN	2023-04-14
506	2020-07-01	JOHN CAIN	2022-04-15
506	2019-07-01	JOHN E CAIN	2021-05-12
506	2019-07-01	JOHN E CAIN	2021-04-15
506	2018-07-01	JOHN E CAIN	2020-04-14
506	2017-07-01	JOHN E CAIN	2019-04-15
506	2016-07-01
506	2015-07-01
506	2014-07-01
506	2013-07-01	JOHN E CAIN
506	2012-07-01	JOHN E CAIN
506	2011-07-01	JOHN E CAIN
506	2010-07-01	JOHN E CAIN
506	2009-07-01	JOHN E CAIN

Plan Statistics for CO-OP HEALTH & WELFARE PLAN AND TRUST

401k plan membership statisitcs for CO-OP HEALTH & WELFARE PLAN AND TRUST

Measure Date Value
2021: CO-OP HEALTH & WELFARE PLAN AND TRUST 2021 401k membership
Total participants, beginning-of-year 2021-07-01 1,673
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 1,738
Number of retired or separated participants receiving benefits 2021-07-01 27
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 1,765
2020: CO-OP HEALTH & WELFARE PLAN AND TRUST 2020 401k membership
Total participants, beginning-of-year 2020-07-01 2,169
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 1,637
Number of retired or separated participants receiving benefits 2020-07-01 36
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 1,673
2019: CO-OP HEALTH & WELFARE PLAN AND TRUST 2019 401k membership
Total participants, beginning-of-year 2019-07-01 2,142
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 2,126
Number of retired or separated participants receiving benefits 2019-07-01 43
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 2,169
2018: CO-OP HEALTH & WELFARE PLAN AND TRUST 2018 401k membership
Total participants, beginning-of-year 2018-07-01 2,180
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 2,097
Number of retired or separated participants receiving benefits 2018-07-01 43
Number of other retired or separated participants entitled to future benefits 2018-07-01 0
Total of all active and inactive participants 2018-07-01 2,140
2017: CO-OP HEALTH & WELFARE PLAN AND TRUST 2017 401k membership
Total participants, beginning-of-year 2017-07-01 2,166
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 2,145
Number of retired or separated participants receiving benefits 2017-07-01 35
Number of other retired or separated participants entitled to future benefits 2017-07-01 0
Total of all active and inactive participants 2017-07-01 2,180
2016: CO-OP HEALTH & WELFARE PLAN AND TRUST 2016 401k membership
Total participants, beginning-of-year 2016-07-01 2,165
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 2,127
Number of retired or separated participants receiving benefits 2016-07-01 39
Number of other retired or separated participants entitled to future benefits 2016-07-01 0
Total of all active and inactive participants 2016-07-01 2,166
2015: CO-OP HEALTH & WELFARE PLAN AND TRUST 2015 401k membership
Total participants, beginning-of-year 2015-07-01 2,209
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 2,118
Number of retired or separated participants receiving benefits 2015-07-01 47
Number of other retired or separated participants entitled to future benefits 2015-07-01 0
Total of all active and inactive participants 2015-07-01 2,165
2014: CO-OP HEALTH & WELFARE PLAN AND TRUST 2014 401k membership
Total participants, beginning-of-year 2014-07-01 2,137
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 2,159
Number of retired or separated participants receiving benefits 2014-07-01 50
Number of other retired or separated participants entitled to future benefits 2014-07-01 0
Total of all active and inactive participants 2014-07-01 2,209
2013: CO-OP HEALTH & WELFARE PLAN AND TRUST 2013 401k membership
Total participants, beginning-of-year 2013-07-01 2,064
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 2,101
Number of retired or separated participants receiving benefits 2013-07-01 36
Number of other retired or separated participants entitled to future benefits 2013-07-01 0
Total of all active and inactive participants 2013-07-01 2,137
2012: CO-OP HEALTH & WELFARE PLAN AND TRUST 2012 401k membership
Total participants, beginning-of-year 2012-07-01 1,710
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 2,012
Number of retired or separated participants receiving benefits 2012-07-01 52
Number of other retired or separated participants entitled to future benefits 2012-07-01 0
Total of all active and inactive participants 2012-07-01 2,064
2011: CO-OP HEALTH & WELFARE PLAN AND TRUST 2011 401k membership
Total participants, beginning-of-year 2011-07-01 1,768
Total number of active participants reported on line 7a of the Form 5500 2011-07-01 1,710
Number of retired or separated participants receiving benefits 2011-07-01 0
Number of other retired or separated participants entitled to future benefits 2011-07-01 0
Total of all active and inactive participants 2011-07-01 1,710
2010: CO-OP HEALTH & WELFARE PLAN AND TRUST 2010 401k membership
Total participants, beginning-of-year 2010-07-01 1,618
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 1,768
Number of retired or separated participants receiving benefits 2010-07-01 0
Number of other retired or separated participants entitled to future benefits 2010-07-01 0
Total of all active and inactive participants 2010-07-01 1,768
2009: CO-OP HEALTH & WELFARE PLAN AND TRUST 2009 401k membership
Total participants, beginning-of-year 2009-07-01 1,744
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 1,618
Number of retired or separated participants receiving benefits 2009-07-01 0
Number of other retired or separated participants entitled to future benefits 2009-07-01 0
Total of all active and inactive participants 2009-07-01 1,618

Measure	Date	Value
2021: CO-OP HEALTH & WELFARE PLAN AND TRUST 2021 401k membership
Total participants, beginning-of-year	2021-07-01	1,673
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	1,738
Number of retired or separated participants receiving benefits	2021-07-01	27
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	1,765
2020: CO-OP HEALTH & WELFARE PLAN AND TRUST 2020 401k membership
Total participants, beginning-of-year	2020-07-01	2,169
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	1,637
Number of retired or separated participants receiving benefits	2020-07-01	36
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	1,673
2019: CO-OP HEALTH & WELFARE PLAN AND TRUST 2019 401k membership
Total participants, beginning-of-year	2019-07-01	2,142
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	2,126
Number of retired or separated participants receiving benefits	2019-07-01	43
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	2,169
2018: CO-OP HEALTH & WELFARE PLAN AND TRUST 2018 401k membership
Total participants, beginning-of-year	2018-07-01	2,180
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	2,097
Number of retired or separated participants receiving benefits	2018-07-01	43
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	2,140
2017: CO-OP HEALTH & WELFARE PLAN AND TRUST 2017 401k membership
Total participants, beginning-of-year	2017-07-01	2,166
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	2,145
Number of retired or separated participants receiving benefits	2017-07-01	35
Number of other retired or separated participants entitled to future benefits	2017-07-01	0
Total of all active and inactive participants	2017-07-01	2,180
2016: CO-OP HEALTH & WELFARE PLAN AND TRUST 2016 401k membership
Total participants, beginning-of-year	2016-07-01	2,165
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	2,127
Number of retired or separated participants receiving benefits	2016-07-01	39
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	2,166
2015: CO-OP HEALTH & WELFARE PLAN AND TRUST 2015 401k membership
Total participants, beginning-of-year	2015-07-01	2,209
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	2,118
Number of retired or separated participants receiving benefits	2015-07-01	47
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	2,165
2014: CO-OP HEALTH & WELFARE PLAN AND TRUST 2014 401k membership
Total participants, beginning-of-year	2014-07-01	2,137
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	2,159
Number of retired or separated participants receiving benefits	2014-07-01	50
Number of other retired or separated participants entitled to future benefits	2014-07-01	0
Total of all active and inactive participants	2014-07-01	2,209
2013: CO-OP HEALTH & WELFARE PLAN AND TRUST 2013 401k membership
Total participants, beginning-of-year	2013-07-01	2,064
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	2,101
Number of retired or separated participants receiving benefits	2013-07-01	36
Number of other retired or separated participants entitled to future benefits	2013-07-01	0
Total of all active and inactive participants	2013-07-01	2,137
2012: CO-OP HEALTH & WELFARE PLAN AND TRUST 2012 401k membership
Total participants, beginning-of-year	2012-07-01	1,710
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	2,012
Number of retired or separated participants receiving benefits	2012-07-01	52
Number of other retired or separated participants entitled to future benefits	2012-07-01	0
Total of all active and inactive participants	2012-07-01	2,064
2011: CO-OP HEALTH & WELFARE PLAN AND TRUST 2011 401k membership
Total participants, beginning-of-year	2011-07-01	1,768
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	1,710
Number of retired or separated participants receiving benefits	2011-07-01	0
Number of other retired or separated participants entitled to future benefits	2011-07-01	0
Total of all active and inactive participants	2011-07-01	1,710
2010: CO-OP HEALTH & WELFARE PLAN AND TRUST 2010 401k membership
Total participants, beginning-of-year	2010-07-01	1,618
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	1,768
Number of retired or separated participants receiving benefits	2010-07-01	0
Number of other retired or separated participants entitled to future benefits	2010-07-01	0
Total of all active and inactive participants	2010-07-01	1,768
2009: CO-OP HEALTH & WELFARE PLAN AND TRUST 2009 401k membership
Total participants, beginning-of-year	2009-07-01	1,744
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	1,618
Number of retired or separated participants receiving benefits	2009-07-01	0
Number of other retired or separated participants entitled to future benefits	2009-07-01	0
Total of all active and inactive participants	2009-07-01	1,618

Financial Data on CO-OP HEALTH & WELFARE PLAN AND TRUST

Measure	Date	Value
2022 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2022 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2022-06-30	$-1,217,875
Total unrealized appreciation/depreciation of assets	2022-06-30	$-1,217,875
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-06-30	$3,456,528
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-06-30	$4,430,298
Total income from all sources (including contributions)	2022-06-30	$21,080,684
Total loss/gain on sale of assets	2022-06-30	$-36,886
Total of all expenses incurred	2022-06-30	$19,737,556
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-06-30	$18,833,312
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-06-30	$22,013,790
Value of total assets at end of year	2022-06-30	$16,259,334
Value of total assets at beginning of year	2022-06-30	$15,889,976
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-06-30	$904,244
Total interest from all sources	2022-06-30	$321,655
Total dividends received (eg from common stock, registered investment company shares)	2022-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-06-30	No
Was this plan covered by a fidelity bond	2022-06-30	Yes
Value of fidelity bond cover	2022-06-30	$500,000
If this is an individual account plan, was there a blackout period	2022-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2022-06-30	No
Contributions received from participants	2022-06-30	$6,025,174
Participant contributions at end of year	2022-06-30	$11,467
Participant contributions at beginning of year	2022-06-30	$2,136
Value of other receiveables (less allowance for doubtful accounts) at end of year	2022-06-30	$76,219
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2022-06-30	$70,801
Administrative expenses (other) incurred	2022-06-30	$48,561
Liabilities. Value of operating payables at end of year	2022-06-30	$70
Liabilities. Value of operating payables at beginning of year	2022-06-30	$0
Total non interest bearing cash at end of year	2022-06-30	$3,013,717
Total non interest bearing cash at beginning of year	2022-06-30	$2,692,799
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-06-30	No
Value of net income/loss	2022-06-30	$1,343,128
Value of net assets at end of year (total assets less liabilities)	2022-06-30	$12,802,806
Value of net assets at beginning of year (total assets less liabilities)	2022-06-30	$11,459,678
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-06-30	No
Were any leases to which the plan was party in default or uncollectible	2022-06-30	No
Investment advisory and management fees	2022-06-30	$22,521
Income. Interest from US Government securities	2022-06-30	$117,473
Income. Interest from corporate debt instruments	2022-06-30	$203,856
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2022-06-30	$527,975
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2022-06-30	$656,375
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2022-06-30	$656,375
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2022-06-30	$326
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2022-06-30	$2,464,954
Asset value of US Government securities at end of year	2022-06-30	$7,749,465
Asset value of US Government securities at beginning of year	2022-06-30	$6,049,777
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-06-30	Yes
Was there a failure to transmit to the plan any participant contributions	2022-06-30	No
Has the plan failed to provide any benefit when due under the plan	2022-06-30	No
Contributions received in cash from employer	2022-06-30	$15,988,616
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-06-30	$16,368,358
Asset. Corporate debt instrument preferred debt at end of year	2022-06-30	$4,880,491
Asset. Corporate debt instrument preferred debt at beginning of year	2022-06-30	$6,418,088
Contract administrator fees	2022-06-30	$833,162
Liabilities. Value of benefit claims payable at end of year	2022-06-30	$3,456,458
Liabilities. Value of benefit claims payable at beginning of year	2022-06-30	$4,430,298
Did the plan have assets held for investment	2022-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-06-30	No
Aggregate proceeds on sale of assets	2022-06-30	$9,049,154
Aggregate carrying amount (costs) on sale of assets	2022-06-30	$9,086,040
Opinion of an independent qualified public accountant for this plan	2022-06-30	Unqualified
Accountancy firm name	2022-06-30	CROWE LLP
Accountancy firm EIN	2022-06-30	350921680
2021 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2021 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2021-06-30	$-382,546
Total unrealized appreciation/depreciation of assets	2021-06-30	$-382,546
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-06-30	$4,430,298
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-06-30	$4,906,625
Total income from all sources (including contributions)	2021-06-30	$22,409,830
Total loss/gain on sale of assets	2021-06-30	$108,373
Total of all expenses incurred	2021-06-30	$22,031,340
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-06-30	$20,899,141
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-06-30	$22,321,283
Value of total assets at end of year	2021-06-30	$15,889,976
Value of total assets at beginning of year	2021-06-30	$15,987,813
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-06-30	$1,132,199
Total interest from all sources	2021-06-30	$362,720
Total dividends received (eg from common stock, registered investment company shares)	2021-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-06-30	No
Was this plan covered by a fidelity bond	2021-06-30	Yes
Value of fidelity bond cover	2021-06-30	$500,000
If this is an individual account plan, was there a blackout period	2021-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2021-06-30	No
Contributions received from participants	2021-06-30	$6,109,335
Participant contributions at end of year	2021-06-30	$2,136
Participant contributions at beginning of year	2021-06-30	$4,313
Value of other receiveables (less allowance for doubtful accounts) at end of year	2021-06-30	$70,801
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2021-06-30	$78,565
Administrative expenses (other) incurred	2021-06-30	$52,374
Total non interest bearing cash at end of year	2021-06-30	$2,692,799
Total non interest bearing cash at beginning of year	2021-06-30	$1,102,738
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-06-30	No
Value of net income/loss	2021-06-30	$378,490
Value of net assets at end of year (total assets less liabilities)	2021-06-30	$11,459,678
Value of net assets at beginning of year (total assets less liabilities)	2021-06-30	$11,081,188
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-06-30	No
Were any leases to which the plan was party in default or uncollectible	2021-06-30	No
Investment advisory and management fees	2021-06-30	$24,063
Income. Interest from US Government securities	2021-06-30	$135,047
Income. Interest from corporate debt instruments	2021-06-30	$227,639
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2021-06-30	$656,375
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2021-06-30	$122,137
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2021-06-30	$122,137
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2021-06-30	$34
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2021-06-30	$2,583,308
Asset value of US Government securities at end of year	2021-06-30	$6,049,777
Asset value of US Government securities at beginning of year	2021-06-30	$8,018,985
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-06-30	No
Was there a failure to transmit to the plan any participant contributions	2021-06-30	No
Has the plan failed to provide any benefit when due under the plan	2021-06-30	No
Contributions received in cash from employer	2021-06-30	$16,211,948
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-06-30	$18,315,833
Asset. Corporate debt instrument preferred debt at end of year	2021-06-30	$6,418,088
Asset. Corporate debt instrument preferred debt at beginning of year	2021-06-30	$6,661,075
Contract administrator fees	2021-06-30	$1,055,762
Liabilities. Value of benefit claims payable at end of year	2021-06-30	$4,430,298
Liabilities. Value of benefit claims payable at beginning of year	2021-06-30	$4,906,625
Did the plan have assets held for investment	2021-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-06-30	No
Aggregate proceeds on sale of assets	2021-06-30	$17,066,907
Aggregate carrying amount (costs) on sale of assets	2021-06-30	$16,958,534
Opinion of an independent qualified public accountant for this plan	2021-06-30	Disclaimer
Accountancy firm name	2021-06-30	CROWE LLP
Accountancy firm EIN	2021-06-30	350921680
2020 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2020 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2020-06-30	$467,731
Total unrealized appreciation/depreciation of assets	2020-06-30	$467,731
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-06-30	$4,906,625
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-06-30	$4,607,068
Total income from all sources (including contributions)	2020-06-30	$24,479,620
Total loss/gain on sale of assets	2020-06-30	$99,755
Total of all expenses incurred	2020-06-30	$25,263,181
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-06-30	$24,165,062
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-06-30	$23,482,748
Value of total assets at end of year	2020-06-30	$15,987,813
Value of total assets at beginning of year	2020-06-30	$16,471,817
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-06-30	$1,098,119
Total interest from all sources	2020-06-30	$429,386
Total dividends received (eg from common stock, registered investment company shares)	2020-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-06-30	No
Was this plan covered by a fidelity bond	2020-06-30	Yes
Value of fidelity bond cover	2020-06-30	$500,000
If this is an individual account plan, was there a blackout period	2020-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2020-06-30	No
Contributions received from participants	2020-06-30	$6,429,576
Participant contributions at end of year	2020-06-30	$4,313
Participant contributions at beginning of year	2020-06-30	$119,388
Value of other receiveables (less allowance for doubtful accounts) at end of year	2020-06-30	$78,565
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2020-06-30	$92,581
Administrative expenses (other) incurred	2020-06-30	$47,372
Total non interest bearing cash at end of year	2020-06-30	$1,102,738
Total non interest bearing cash at beginning of year	2020-06-30	$1,443,147
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-06-30	No
Value of net income/loss	2020-06-30	$-783,561
Value of net assets at end of year (total assets less liabilities)	2020-06-30	$11,081,188
Value of net assets at beginning of year (total assets less liabilities)	2020-06-30	$11,864,749
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-06-30	No
Were any leases to which the plan was party in default or uncollectible	2020-06-30	No
Investment advisory and management fees	2020-06-30	$25,277
Income. Interest from US Government securities	2020-06-30	$214,055
Income. Interest from corporate debt instruments	2020-06-30	$212,503
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2020-06-30	$122,137
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2020-06-30	$303,025
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2020-06-30	$303,025
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2020-06-30	$2,828
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2020-06-30	$2,838,950
Asset value of US Government securities at end of year	2020-06-30	$8,018,985
Asset value of US Government securities at beginning of year	2020-06-30	$8,243,778
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-06-30	No
Was there a failure to transmit to the plan any participant contributions	2020-06-30	No
Has the plan failed to provide any benefit when due under the plan	2020-06-30	No
Contributions received in cash from employer	2020-06-30	$17,053,172
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-06-30	$21,326,112
Asset. Corporate debt instrument preferred debt at end of year	2020-06-30	$6,661,075
Asset. Corporate debt instrument preferred debt at beginning of year	2020-06-30	$6,269,898
Contract administrator fees	2020-06-30	$1,025,470
Liabilities. Value of benefit claims payable at end of year	2020-06-30	$4,906,625
Liabilities. Value of benefit claims payable at beginning of year	2020-06-30	$4,607,068
Did the plan have assets held for investment	2020-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-06-30	No
Aggregate proceeds on sale of assets	2020-06-30	$13,490,442
Aggregate carrying amount (costs) on sale of assets	2020-06-30	$13,390,687
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2020-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2020-06-30	Disclaimer
Accountancy firm name	2020-06-30	CROWE LLP
Accountancy firm EIN	2020-06-30	350921680
2019 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2019 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2019-06-30	$674,224
Total unrealized appreciation/depreciation of assets	2019-06-30	$674,224
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-06-30	$4,607,068
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-06-30	$4,734,548
Total income from all sources (including contributions)	2019-06-30	$24,074,209
Total loss/gain on sale of assets	2019-06-30	$-149,596
Total of all expenses incurred	2019-06-30	$22,674,070
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-06-30	$21,289,685
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-06-30	$23,147,372
Value of total assets at end of year	2019-06-30	$16,471,817
Value of total assets at beginning of year	2019-06-30	$15,199,158
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-06-30	$1,384,385
Total interest from all sources	2019-06-30	$402,209
Total dividends received (eg from common stock, registered investment company shares)	2019-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-06-30	No
Was this plan covered by a fidelity bond	2019-06-30	Yes
Value of fidelity bond cover	2019-06-30	$500,000
If this is an individual account plan, was there a blackout period	2019-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2019-06-30	No
Contributions received from participants	2019-06-30	$6,342,380
Participant contributions at end of year	2019-06-30	$119,388
Participant contributions at beginning of year	2019-06-30	$9,929
Value of other receiveables (less allowance for doubtful accounts) at end of year	2019-06-30	$92,581
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2019-06-30	$83,903
Administrative expenses (other) incurred	2019-06-30	$59,689
Total non interest bearing cash at end of year	2019-06-30	$1,443,147
Total non interest bearing cash at beginning of year	2019-06-30	$2,169,459
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-06-30	No
Value of net income/loss	2019-06-30	$1,400,139
Value of net assets at end of year (total assets less liabilities)	2019-06-30	$11,864,749
Value of net assets at beginning of year (total assets less liabilities)	2019-06-30	$10,464,610
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-06-30	No
Were any leases to which the plan was party in default or uncollectible	2019-06-30	No
Investment advisory and management fees	2019-06-30	$22,262
Income. Interest from US Government securities	2019-06-30	$186,707
Income. Interest from corporate debt instruments	2019-06-30	$211,360
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2019-06-30	$303,025
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2019-06-30	$34,364
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2019-06-30	$34,364
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2019-06-30	$4,142
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2019-06-30	$2,544,237
Asset value of US Government securities at end of year	2019-06-30	$8,243,778
Asset value of US Government securities at beginning of year	2019-06-30	$6,677,779
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-06-30	No
Was there a failure to transmit to the plan any participant contributions	2019-06-30	No
Has the plan failed to provide any benefit when due under the plan	2019-06-30	No
Contributions received in cash from employer	2019-06-30	$16,804,992
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-06-30	$18,745,448
Asset. Corporate debt instrument preferred debt at end of year	2019-06-30	$6,269,898
Asset. Corporate debt instrument preferred debt at beginning of year	2019-06-30	$6,223,724
Contract administrator fees	2019-06-30	$1,302,434
Liabilities. Value of benefit claims payable at end of year	2019-06-30	$4,607,068
Liabilities. Value of benefit claims payable at beginning of year	2019-06-30	$4,734,548
Did the plan have assets held for investment	2019-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-06-30	No
Aggregate proceeds on sale of assets	2019-06-30	$17,384,214
Aggregate carrying amount (costs) on sale of assets	2019-06-30	$17,533,810
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2019-06-30	Disclaimer
Accountancy firm name	2019-06-30	CROWE LLP
Accountancy firm EIN	2019-06-30	350921680
2018 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2018 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2018-06-30	$-30,663
Total unrealized appreciation/depreciation of assets	2018-06-30	$-30,663
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-06-30	$4,734,548
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-06-30	$4,217,828
Total income from all sources (including contributions)	2018-06-30	$22,949,787
Total loss/gain on sale of assets	2018-06-30	$-67,425
Total of all expenses incurred	2018-06-30	$22,731,747
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-06-30	$21,439,389
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-06-30	$22,995,046
Value of total assets at end of year	2018-06-30	$15,199,158
Value of total assets at beginning of year	2018-06-30	$14,464,398
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-06-30	$1,292,358
Total interest from all sources	2018-06-30	$52,829
Total dividends received (eg from common stock, registered investment company shares)	2018-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-06-30	No
Was this plan covered by a fidelity bond	2018-06-30	Yes
Value of fidelity bond cover	2018-06-30	$500,000
If this is an individual account plan, was there a blackout period	2018-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2018-06-30	No
Contributions received from participants	2018-06-30	$6,208,662
Participant contributions at end of year	2018-06-30	$9,929
Participant contributions at beginning of year	2018-06-30	$4,692
Value of other receiveables (less allowance for doubtful accounts) at end of year	2018-06-30	$83,903
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2018-06-30	$78,808
Administrative expenses (other) incurred	2018-06-30	$37,423
Liabilities. Value of operating payables at end of year	2018-06-30	$0
Liabilities. Value of operating payables at beginning of year	2018-06-30	$30,503
Total non interest bearing cash at end of year	2018-06-30	$2,169,459
Total non interest bearing cash at beginning of year	2018-06-30	$2,844,467
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-06-30	No
Value of net income/loss	2018-06-30	$218,040
Value of net assets at end of year (total assets less liabilities)	2018-06-30	$10,464,610
Value of net assets at beginning of year (total assets less liabilities)	2018-06-30	$10,246,570
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-06-30	No
Were any leases to which the plan was party in default or uncollectible	2018-06-30	No
Investment advisory and management fees	2018-06-30	$20,659
Income. Interest from US Government securities	2018-06-30	$27,999
Income. Interest from corporate debt instruments	2018-06-30	$24,687
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2018-06-30	$34,364
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2018-06-30	$196,426
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2018-06-30	$196,426
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2018-06-30	$143
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2018-06-30	$2,438,437
Asset value of US Government securities at end of year	2018-06-30	$6,677,779
Asset value of US Government securities at beginning of year	2018-06-30	$8,905,717
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-06-30	No
Was there a failure to transmit to the plan any participant contributions	2018-06-30	No
Has the plan failed to provide any benefit when due under the plan	2018-06-30	No
Contributions received in cash from employer	2018-06-30	$16,786,384
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-06-30	$19,000,952
Asset. Corporate debt instrument preferred debt at end of year	2018-06-30	$6,223,724
Asset. Corporate debt instrument preferred debt at beginning of year	2018-06-30	$2,434,288
Contract administrator fees	2018-06-30	$1,234,276
Liabilities. Value of benefit claims payable at end of year	2018-06-30	$4,734,548
Liabilities. Value of benefit claims payable at beginning of year	2018-06-30	$4,187,325
Did the plan have assets held for investment	2018-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-06-30	No
Aggregate proceeds on sale of assets	2018-06-30	$6,721,964
Aggregate carrying amount (costs) on sale of assets	2018-06-30	$6,789,389
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2018-06-30	Disclaimer
Accountancy firm name	2018-06-30	CROWE LLP
Accountancy firm EIN	2018-06-30	350921680
2017 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2017 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2017-06-30	$-33,851
Total unrealized appreciation/depreciation of assets	2017-06-30	$-33,851
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-06-30	$4,217,828
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-06-30	$5,447,580
Total income from all sources (including contributions)	2017-06-30	$22,335,279
Total loss/gain on sale of assets	2017-06-30	$-79,335
Total of all expenses incurred	2017-06-30	$20,558,663
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-06-30	$19,200,303
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-06-30	$22,291,839
Value of total assets at end of year	2017-06-30	$14,464,398
Value of total assets at beginning of year	2017-06-30	$13,917,534
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-06-30	$1,358,360
Total interest from all sources	2017-06-30	$156,626
Total dividends received (eg from common stock, registered investment company shares)	2017-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-06-30	No
Was this plan covered by a fidelity bond	2017-06-30	Yes
Value of fidelity bond cover	2017-06-30	$500,000
If this is an individual account plan, was there a blackout period	2017-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2017-06-30	No
Contributions received from participants	2017-06-30	$5,963,067
Participant contributions at end of year	2017-06-30	$4,692
Participant contributions at beginning of year	2017-06-30	$7,805
Value of other receiveables (less allowance for doubtful accounts) at end of year	2017-06-30	$78,808
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2017-06-30	$92,508
Administrative expenses (other) incurred	2017-06-30	$153,050
Liabilities. Value of operating payables at end of year	2017-06-30	$30,503
Liabilities. Value of operating payables at beginning of year	2017-06-30	$30,503
Total non interest bearing cash at end of year	2017-06-30	$2,844,467
Total non interest bearing cash at beginning of year	2017-06-30	$1,614,794
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-06-30	No
Value of net income/loss	2017-06-30	$1,776,616
Value of net assets at end of year (total assets less liabilities)	2017-06-30	$10,246,570
Value of net assets at beginning of year (total assets less liabilities)	2017-06-30	$8,469,954
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-06-30	No
Were any leases to which the plan was party in default or uncollectible	2017-06-30	No
Investment advisory and management fees	2017-06-30	$22,179
Income. Interest from US Government securities	2017-06-30	$56,777
Income. Interest from corporate debt instruments	2017-06-30	$99,442
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2017-06-30	$196,426
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2017-06-30	$366,700
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2017-06-30	$366,700
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2017-06-30	$407
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2017-06-30	$2,045,272
Asset value of US Government securities at end of year	2017-06-30	$8,905,717
Asset value of US Government securities at beginning of year	2017-06-30	$7,684,683
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-06-30	Yes
Was there a failure to transmit to the plan any participant contributions	2017-06-30	No
Has the plan failed to provide any benefit when due under the plan	2017-06-30	No
Contributions received in cash from employer	2017-06-30	$16,328,772
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-06-30	$17,155,031
Asset. Corporate debt instrument preferred debt at end of year	2017-06-30	$2,434,288
Asset. Corporate debt instrument preferred debt at beginning of year	2017-06-30	$4,151,044
Contract administrator fees	2017-06-30	$1,183,131
Liabilities. Value of benefit claims payable at end of year	2017-06-30	$4,187,325
Liabilities. Value of benefit claims payable at beginning of year	2017-06-30	$5,417,077
Did the plan have assets held for investment	2017-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-06-30	No
Aggregate proceeds on sale of assets	2017-06-30	$7,389,306
Aggregate carrying amount (costs) on sale of assets	2017-06-30	$7,468,641
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2017-06-30	Disclaimer
Accountancy firm name	2017-06-30	CROWE HORWATH LLP
Accountancy firm EIN	2017-06-30	350921680
2016 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2016 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2016-06-30	$36,190
Total unrealized appreciation/depreciation of assets	2016-06-30	$36,190
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-06-30	$5,447,580
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-06-30	$4,991,182
Total income from all sources (including contributions)	2016-06-30	$22,147,793
Total loss/gain on sale of assets	2016-06-30	$-81,766
Total of all expenses incurred	2016-06-30	$21,696,731
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-06-30	$20,267,771
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-06-30	$21,961,759
Value of total assets at end of year	2016-06-30	$13,917,534
Value of total assets at beginning of year	2016-06-30	$13,010,074
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-06-30	$1,428,960
Total interest from all sources	2016-06-30	$231,610
Total dividends received (eg from common stock, registered investment company shares)	2016-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-06-30	No
Was this plan covered by a fidelity bond	2016-06-30	Yes
Value of fidelity bond cover	2016-06-30	$1,000,000
If this is an individual account plan, was there a blackout period	2016-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2016-06-30	No
Contributions received from participants	2016-06-30	$5,929,675
Participant contributions at end of year	2016-06-30	$7,805
Participant contributions at beginning of year	2016-06-30	$6,315
Value of other receiveables (less allowance for doubtful accounts) at end of year	2016-06-30	$92,508
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2016-06-30	$91,487
Administrative expenses (other) incurred	2016-06-30	$213,556
Liabilities. Value of operating payables at end of year	2016-06-30	$30,503
Liabilities. Value of operating payables at beginning of year	2016-06-30	$39,249
Total non interest bearing cash at end of year	2016-06-30	$1,614,794
Total non interest bearing cash at beginning of year	2016-06-30	$1,624,441
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-06-30	No
Value of net income/loss	2016-06-30	$451,062
Value of net assets at end of year (total assets less liabilities)	2016-06-30	$8,469,954
Value of net assets at beginning of year (total assets less liabilities)	2016-06-30	$8,018,892
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-06-30	No
Were any leases to which the plan was party in default or uncollectible	2016-06-30	No
Investment advisory and management fees	2016-06-30	$20,417
Income. Interest from US Government securities	2016-06-30	$76,198
Income. Interest from corporate debt instruments	2016-06-30	$155,368
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2016-06-30	$366,700
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2016-06-30	$447,519
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2016-06-30	$447,519
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2016-06-30	$44
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2016-06-30	$2,090,296
Asset value of US Government securities at end of year	2016-06-30	$7,684,683
Asset value of US Government securities at beginning of year	2016-06-30	$6,375,067
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-06-30	Yes
Was there a failure to transmit to the plan any participant contributions	2016-06-30	No
Has the plan failed to provide any benefit when due under the plan	2016-06-30	No
Contributions received in cash from employer	2016-06-30	$16,032,084
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-06-30	$18,177,475
Asset. Corporate debt instrument preferred debt at end of year	2016-06-30	$4,151,044
Asset. Corporate debt instrument preferred debt at beginning of year	2016-06-30	$4,465,245
Contract administrator fees	2016-06-30	$1,194,987
Liabilities. Value of benefit claims payable at end of year	2016-06-30	$5,417,077
Liabilities. Value of benefit claims payable at beginning of year	2016-06-30	$4,951,933
Did the plan have assets held for investment	2016-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-06-30	No
Aggregate proceeds on sale of assets	2016-06-30	$17,352,611
Aggregate carrying amount (costs) on sale of assets	2016-06-30	$17,434,377
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2016-06-30	Disclaimer
Accountancy firm name	2016-06-30	CROWE HORWATH LLP
Accountancy firm EIN	2016-06-30	350921680
2015 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2015 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2015-06-30	$-22,381
Total unrealized appreciation/depreciation of assets	2015-06-30	$-22,381
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-06-30	$4,991,182
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-06-30	$4,377,115
Total income from all sources (including contributions)	2015-06-30	$20,861,959
Total loss/gain on sale of assets	2015-06-30	$-65,857
Total of all expenses incurred	2015-06-30	$20,573,836
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-06-30	$19,113,521
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-06-30	$20,746,329
Value of total assets at end of year	2015-06-30	$13,010,074
Value of total assets at beginning of year	2015-06-30	$12,107,884
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-06-30	$1,460,315
Total interest from all sources	2015-06-30	$203,868
Total dividends received (eg from common stock, registered investment company shares)	2015-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-06-30	No
Was this plan covered by a fidelity bond	2015-06-30	Yes
Value of fidelity bond cover	2015-06-30	$1,000,000
If this is an individual account plan, was there a blackout period	2015-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2015-06-30	No
Contributions received from participants	2015-06-30	$5,497,777
Participant contributions at end of year	2015-06-30	$6,315
Participant contributions at beginning of year	2015-06-30	$1,228
Value of other receiveables (less allowance for doubtful accounts) at end of year	2015-06-30	$91,487
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2015-06-30	$105,941
Administrative expenses (other) incurred	2015-06-30	$293,535
Liabilities. Value of operating payables at end of year	2015-06-30	$39,249
Liabilities. Value of operating payables at beginning of year	2015-06-30	$38,695
Total non interest bearing cash at end of year	2015-06-30	$1,624,441
Total non interest bearing cash at beginning of year	2015-06-30	$1,819,921
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-06-30	No
Value of net income/loss	2015-06-30	$288,123
Value of net assets at end of year (total assets less liabilities)	2015-06-30	$8,018,892
Value of net assets at beginning of year (total assets less liabilities)	2015-06-30	$7,730,769
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-06-30	No
Were any leases to which the plan was party in default or uncollectible	2015-06-30	No
Investment advisory and management fees	2015-06-30	$19,028
Income. Interest from US Government securities	2015-06-30	$167,924
Income. Interest from corporate debt instruments	2015-06-30	$35,907
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2015-06-30	$447,519
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2015-06-30	$270,314
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2015-06-30	$270,314
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2015-06-30	$37
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2015-06-30	$2,113,728
Asset value of US Government securities at end of year	2015-06-30	$6,375,067
Asset value of US Government securities at beginning of year	2015-06-30	$6,499,814
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-06-30	Yes
Was there a failure to transmit to the plan any participant contributions	2015-06-30	No
Has the plan failed to provide any benefit when due under the plan	2015-06-30	No
Contributions received in cash from employer	2015-06-30	$15,248,552
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-06-30	$16,999,793
Asset. Corporate debt instrument preferred debt at end of year	2015-06-30	$4,465,245
Asset. Corporate debt instrument preferred debt at beginning of year	2015-06-30	$3,410,666
Contract administrator fees	2015-06-30	$1,147,752
Liabilities. Value of benefit claims payable at end of year	2015-06-30	$4,951,933
Liabilities. Value of benefit claims payable at beginning of year	2015-06-30	$4,338,420
Did the plan have assets held for investment	2015-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-06-30	No
Aggregate proceeds on sale of assets	2015-06-30	$15,926,485
Aggregate carrying amount (costs) on sale of assets	2015-06-30	$15,992,342
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2015-06-30	Disclaimer
Accountancy firm name	2015-06-30	CROWE HORWATH LLP
Accountancy firm EIN	2015-06-30	350921680
2014 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2014 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2014-06-30	$-18,442
Total unrealized appreciation/depreciation of assets	2014-06-30	$-18,442
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-06-30	$4,377,115
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-06-30	$3,978,388
Total income from all sources (including contributions)	2014-06-30	$19,573,489
Total loss/gain on sale of assets	2014-06-30	$-92,044
Total of all expenses incurred	2014-06-30	$20,422,137
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-06-30	$19,225,465
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-06-30	$19,358,655
Value of total assets at end of year	2014-06-30	$12,107,884
Value of total assets at beginning of year	2014-06-30	$12,557,805
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-06-30	$1,196,672
Total interest from all sources	2014-06-30	$325,320
Total dividends received (eg from common stock, registered investment company shares)	2014-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-06-30	No
Was this plan covered by a fidelity bond	2014-06-30	Yes
Value of fidelity bond cover	2014-06-30	$1,000,000
If this is an individual account plan, was there a blackout period	2014-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2014-06-30	No
Contributions received from participants	2014-06-30	$5,130,043
Participant contributions at end of year	2014-06-30	$1,228
Participant contributions at beginning of year	2014-06-30	$21,385
Value of other receiveables (less allowance for doubtful accounts) at end of year	2014-06-30	$105,941
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2014-06-30	$139,698
Administrative expenses (other) incurred	2014-06-30	$36,729
Liabilities. Value of operating payables at end of year	2014-06-30	$38,695
Liabilities. Value of operating payables at beginning of year	2014-06-30	$30,503
Total non interest bearing cash at end of year	2014-06-30	$1,819,921
Total non interest bearing cash at beginning of year	2014-06-30	$1,448,935
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-06-30	No
Value of net income/loss	2014-06-30	$-848,648
Value of net assets at end of year (total assets less liabilities)	2014-06-30	$7,730,769
Value of net assets at beginning of year (total assets less liabilities)	2014-06-30	$8,579,417
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-06-30	No
Were any leases to which the plan was party in default or uncollectible	2014-06-30	No
Investment advisory and management fees	2014-06-30	$19,604
Income. Interest from US Government securities	2014-06-30	$187,233
Income. Interest from corporate debt instruments	2014-06-30	$138,062
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2014-06-30	$270,314
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2014-06-30	$496,556
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2014-06-30	$496,556
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2014-06-30	$25
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2014-06-30	$2,177,935
Asset value of US Government securities at end of year	2014-06-30	$6,499,814
Asset value of US Government securities at beginning of year	2014-06-30	$7,583,724
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-06-30	Yes
Was there a failure to transmit to the plan any participant contributions	2014-06-30	No
Has the plan failed to provide any benefit when due under the plan	2014-06-30	No
Contributions received in cash from employer	2014-06-30	$14,228,612
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-06-30	$17,047,530
Asset. Corporate debt instrument preferred debt at end of year	2014-06-30	$3,410,666
Asset. Corporate debt instrument preferred debt at beginning of year	2014-06-30	$2,867,507
Contract administrator fees	2014-06-30	$1,140,339
Liabilities. Value of benefit claims payable at end of year	2014-06-30	$4,338,420
Liabilities. Value of benefit claims payable at beginning of year	2014-06-30	$3,947,885
Did the plan have assets held for investment	2014-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-06-30	No
Aggregate proceeds on sale of assets	2014-06-30	$15,748,337
Aggregate carrying amount (costs) on sale of assets	2014-06-30	$15,840,381
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2014-06-30	Disclaimer
Accountancy firm name	2014-06-30	CROWE HORWATH LLP
Accountancy firm EIN	2014-06-30	350921680
2013 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2013 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2013-06-30	$-52,503
Total unrealized appreciation/depreciation of assets	2013-06-30	$-52,503
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-06-30	$3,978,388
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-06-30	$5,128,679
Total income from all sources (including contributions)	2013-06-30	$17,552,749
Total loss/gain on sale of assets	2013-06-30	$-72,881
Total of all expenses incurred	2013-06-30	$14,603,285
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-06-30	$13,579,677
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-06-30	$17,398,824
Value of total assets at end of year	2013-06-30	$12,557,805
Value of total assets at beginning of year	2013-06-30	$10,758,632
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-06-30	$1,023,608
Total interest from all sources	2013-06-30	$279,309
Total dividends received (eg from common stock, registered investment company shares)	2013-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-06-30	No
Was this plan covered by a fidelity bond	2013-06-30	Yes
Value of fidelity bond cover	2013-06-30	$1,000,000
If this is an individual account plan, was there a blackout period	2013-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2013-06-30	No
Contributions received from participants	2013-06-30	$4,784,677
Participant contributions at end of year	2013-06-30	$21,385
Participant contributions at beginning of year	2013-06-30	$4,285
Value of other receiveables (less allowance for doubtful accounts) at end of year	2013-06-30	$139,698
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2013-06-30	$142,216
Administrative expenses (other) incurred	2013-06-30	$30,308
Liabilities. Value of operating payables at end of year	2013-06-30	$30,503
Liabilities. Value of operating payables at beginning of year	2013-06-30	$34,756
Total non interest bearing cash at end of year	2013-06-30	$1,448,935
Total non interest bearing cash at beginning of year	2013-06-30	$2,003,013
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-06-30	No
Value of net income/loss	2013-06-30	$2,949,464
Value of net assets at end of year (total assets less liabilities)	2013-06-30	$8,579,417
Value of net assets at beginning of year (total assets less liabilities)	2013-06-30	$5,629,953
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-06-30	No
Were any leases to which the plan was party in default or uncollectible	2013-06-30	No
Investment advisory and management fees	2013-06-30	$13,521
Income. Interest from US Government securities	2013-06-30	$203,245
Income. Interest from corporate debt instruments	2013-06-30	$76,054
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2013-06-30	$496,556
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2013-06-30	$440,142
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2013-06-30	$440,142
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2013-06-30	$10
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2013-06-30	$1,750,480
Asset value of US Government securities at end of year	2013-06-30	$7,583,724
Asset value of US Government securities at beginning of year	2013-06-30	$6,776,220
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-06-30	No
Was there a failure to transmit to the plan any participant contributions	2013-06-30	No
Has the plan failed to provide any benefit when due under the plan	2013-06-30	No
Contributions received in cash from employer	2013-06-30	$12,614,147
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-06-30	$11,829,197
Asset. Corporate debt instrument preferred debt at end of year	2013-06-30	$2,867,507
Asset. Corporate debt instrument preferred debt at beginning of year	2013-06-30	$1,392,756
Contract administrator fees	2013-06-30	$979,779
Liabilities. Value of benefit claims payable at end of year	2013-06-30	$3,947,885
Liabilities. Value of benefit claims payable at beginning of year	2013-06-30	$5,093,923
Did the plan have assets held for investment	2013-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-06-30	No
Aggregate proceeds on sale of assets	2013-06-30	$19,331,116
Aggregate carrying amount (costs) on sale of assets	2013-06-30	$19,403,997
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2013-06-30	Disclaimer
Accountancy firm name	2013-06-30	CROWE HORWATH LLP
Accountancy firm EIN	2013-06-30	350921680
2012 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2012 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2012-06-30	$-16,594
Total unrealized appreciation/depreciation of assets	2012-06-30	$-16,594
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-06-30	$5,128,679
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-06-30	$5,512,251
Total income from all sources (including contributions)	2012-06-30	$16,144,721
Total loss/gain on sale of assets	2012-06-30	$-45,263
Total of all expenses incurred	2012-06-30	$15,537,941
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-06-30	$14,645,000
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-06-30	$15,907,012
Value of total assets at end of year	2012-06-30	$10,758,632
Value of total assets at beginning of year	2012-06-30	$10,535,424
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-06-30	$892,941
Total interest from all sources	2012-06-30	$299,566
Total dividends received (eg from common stock, registered investment company shares)	2012-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-06-30	No
Was this plan covered by a fidelity bond	2012-06-30	Yes
Value of fidelity bond cover	2012-06-30	$5,000,000
If this is an individual account plan, was there a blackout period	2012-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2012-06-30	No
Contributions received from participants	2012-06-30	$5,726,524
Participant contributions at end of year	2012-06-30	$4,285
Participant contributions at beginning of year	2012-06-30	$24,182
Value of other receiveables (less allowance for doubtful accounts) at end of year	2012-06-30	$142,216
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2012-06-30	$137,299
Administrative expenses (other) incurred	2012-06-30	$22,692
Liabilities. Value of operating payables at end of year	2012-06-30	$34,756
Liabilities. Value of operating payables at beginning of year	2012-06-30	$34,689
Total non interest bearing cash at end of year	2012-06-30	$2,003,013
Total non interest bearing cash at beginning of year	2012-06-30	$1,980,759
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-06-30	No
Value of net income/loss	2012-06-30	$606,780
Value of net assets at end of year (total assets less liabilities)	2012-06-30	$5,629,953
Value of net assets at beginning of year (total assets less liabilities)	2012-06-30	$5,023,173
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-06-30	No
Were any leases to which the plan was party in default or uncollectible	2012-06-30	No
Investment advisory and management fees	2012-06-30	$16,925
Income. Interest from US Government securities	2012-06-30	$222,955
Income. Interest from corporate debt instruments	2012-06-30	$76,603
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-06-30	$440,142
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-06-30	$161,956
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-06-30	$161,956
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2012-06-30	$8
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2012-06-30	$2,555,335
Asset value of US Government securities at end of year	2012-06-30	$6,776,220
Asset value of US Government securities at beginning of year	2012-06-30	$6,621,337
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-06-30	Yes
Was there a failure to transmit to the plan any participant contributions	2012-06-30	No
Has the plan failed to provide any benefit when due under the plan	2012-06-30	No
Contributions received in cash from employer	2012-06-30	$10,180,488
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-06-30	$12,089,665
Asset. Corporate debt instrument preferred debt at end of year	2012-06-30	$1,392,756
Asset. Corporate debt instrument preferred debt at beginning of year	2012-06-30	$1,609,891
Contract administrator fees	2012-06-30	$853,324
Liabilities. Value of benefit claims payable at end of year	2012-06-30	$5,093,923
Liabilities. Value of benefit claims payable at beginning of year	2012-06-30	$5,477,562
Did the plan have assets held for investment	2012-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-06-30	No
Aggregate proceeds on sale of assets	2012-06-30	$14,120,667
Aggregate carrying amount (costs) on sale of assets	2012-06-30	$14,165,930
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-06-30	Yes
Opinion of an independent qualified public accountant for this plan	2012-06-30	Disclaimer
Accountancy firm name	2012-06-30	CROWE HORWATH LLP
Accountancy firm EIN	2012-06-30	350921680
2011 : CO-OP HEALTH & WELFARE PLAN AND TRUST 2011 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2011-06-30	$-13,866
Total unrealized appreciation/depreciation of assets	2011-06-30	$-13,866
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-06-30	$5,512,251
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-06-30	$5,926,546
Total income from all sources (including contributions)	2011-06-30	$14,946,664
Total loss/gain on sale of assets	2011-06-30	$-69,451
Total of all expenses incurred	2011-06-30	$14,106,847
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-06-30	$13,146,130
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-06-30	$14,685,351
Value of total assets at end of year	2011-06-30	$10,535,424
Value of total assets at beginning of year	2011-06-30	$10,109,902
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-06-30	$960,717
Total interest from all sources	2011-06-30	$344,630
Total dividends received (eg from common stock, registered investment company shares)	2011-06-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-06-30	No
Was this plan covered by a fidelity bond	2011-06-30	Yes
Value of fidelity bond cover	2011-06-30	$5,000,000
If this is an individual account plan, was there a blackout period	2011-06-30	No
Were there any nonexempt tranactions with any party-in-interest	2011-06-30	No
Contributions received from participants	2011-06-30	$5,580,433
Participant contributions at end of year	2011-06-30	$24,182
Participant contributions at beginning of year	2011-06-30	$1,285
Value of other receiveables (less allowance for doubtful accounts) at end of year	2011-06-30	$137,299
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2011-06-30	$205,683
Administrative expenses (other) incurred	2011-06-30	$49,639
Liabilities. Value of operating payables at end of year	2011-06-30	$34,689
Liabilities. Value of operating payables at beginning of year	2011-06-30	$26,212
Total non interest bearing cash at end of year	2011-06-30	$1,980,759
Total non interest bearing cash at beginning of year	2011-06-30	$1,176,867
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-06-30	No
Value of net income/loss	2011-06-30	$839,817
Value of net assets at end of year (total assets less liabilities)	2011-06-30	$5,023,173
Value of net assets at beginning of year (total assets less liabilities)	2011-06-30	$4,183,356
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-06-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-06-30	No
Were any leases to which the plan was party in default or uncollectible	2011-06-30	No
Investment advisory and management fees	2011-06-30	$16,943
Income. Interest from US Government securities	2011-06-30	$259,101
Income. Interest from corporate debt instruments	2011-06-30	$85,524
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-06-30	$161,956
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-06-30	$86,906
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-06-30	$86,906
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2011-06-30	$5
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-06-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-06-30	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2011-06-30	$1,745,325
Asset value of US Government securities at end of year	2011-06-30	$6,621,337
Asset value of US Government securities at beginning of year	2011-06-30	$6,905,371
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-06-30	No
Was there a failure to transmit to the plan any participant contributions	2011-06-30	No
Has the plan failed to provide any benefit when due under the plan	2011-06-30	No
Contributions received in cash from employer	2011-06-30	$9,104,918
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-06-30	$11,400,805
Asset. Corporate debt instrument preferred debt at end of year	2011-06-30	$1,609,891
Asset. Corporate debt instrument preferred debt at beginning of year	2011-06-30	$1,733,790
Contract administrator fees	2011-06-30	$894,135
Liabilities. Value of benefit claims payable at end of year	2011-06-30	$5,477,562
Liabilities. Value of benefit claims payable at beginning of year	2011-06-30	$5,900,334
Did the plan have assets held for investment	2011-06-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-06-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-06-30	No
Aggregate proceeds on sale of assets	2011-06-30	$13,969,064
Aggregate carrying amount (costs) on sale of assets	2011-06-30	$14,038,515
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-06-30	No
Opinion of an independent qualified public accountant for this plan	2011-06-30	Unqualified
Accountancy firm name	2011-06-30	CROWE HORWATH LLP
Accountancy firm EIN	2011-06-30	350921680

Form 5500 Responses for CO-OP HEALTH & WELFARE PLAN AND TRUST

2021: CO-OP HEALTH & WELFARE PLAN AND TRUST 2021 form 5500 responses
2021-07-01	Type of plan entity	Mulitple employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – Trust	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement - Trust	Yes
2020: CO-OP HEALTH & WELFARE PLAN AND TRUST 2020 form 5500 responses
2020-07-01	Type of plan entity	Mulitple employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – Trust	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement - Trust	Yes
2019: CO-OP HEALTH & WELFARE PLAN AND TRUST 2019 form 5500 responses
2019-07-01	Type of plan entity	Mulitple employer plan
2019-07-01	Submission has been amended	Yes
2019-07-01	This submission is the final filing	No
2019-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-07-01	Plan is a collectively bargained plan	No
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – Trust	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement - Trust	Yes
2018: CO-OP HEALTH & WELFARE PLAN AND TRUST 2018 form 5500 responses
2018-07-01	Type of plan entity	Mulitple employer plan
2018-07-01	Submission has been amended	No
2018-07-01	This submission is the final filing	No
2018-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-07-01	Plan is a collectively bargained plan	No
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – Trust	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement - Trust	Yes
2017: CO-OP HEALTH & WELFARE PLAN AND TRUST 2017 form 5500 responses
2017-07-01	Type of plan entity	Mulitple employer plan
2017-07-01	Submission has been amended	No
2017-07-01	This submission is the final filing	No
2017-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-07-01	Plan is a collectively bargained plan	No
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – Trust	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement - Trust	Yes
2016: CO-OP HEALTH & WELFARE PLAN AND TRUST 2016 form 5500 responses
2016-07-01	Type of plan entity	Mulitple employer plan
2016-07-01	Submission has been amended	No
2016-07-01	This submission is the final filing	No
2016-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-07-01	Plan is a collectively bargained plan	No
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – Trust	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement - Trust	Yes
2015: CO-OP HEALTH & WELFARE PLAN AND TRUST 2015 form 5500 responses
2015-07-01	Type of plan entity	Mulitple employer plan
2015-07-01	Submission has been amended	No
2015-07-01	This submission is the final filing	No
2015-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-07-01	Plan is a collectively bargained plan	No
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – Trust	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement - Trust	Yes
2014: CO-OP HEALTH & WELFARE PLAN AND TRUST 2014 form 5500 responses
2014-07-01	Type of plan entity	Mulitple employer plan
2014-07-01	Submission has been amended	No
2014-07-01	This submission is the final filing	No
2014-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-07-01	Plan is a collectively bargained plan	No
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – Trust	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement - Trust	Yes
2013: CO-OP HEALTH & WELFARE PLAN AND TRUST 2013 form 5500 responses
2013-07-01	Type of plan entity	Mulitple employer plan
2013-07-01	Submission has been amended	No
2013-07-01	This submission is the final filing	No
2013-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-07-01	Plan is a collectively bargained plan	No
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – Trust	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement - Trust	Yes
2012: CO-OP HEALTH & WELFARE PLAN AND TRUST 2012 form 5500 responses
2012-07-01	Type of plan entity	Mulitple employer plan
2012-07-01	Submission has been amended	No
2012-07-01	This submission is the final filing	No
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-07-01	Plan is a collectively bargained plan	No
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan funding arrangement – Trust	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement - Trust	Yes
2011: CO-OP HEALTH & WELFARE PLAN AND TRUST 2011 form 5500 responses
2011-07-01	Type of plan entity	Mulitple employer plan
2011-07-01	Submission has been amended	No
2011-07-01	This submission is the final filing	No
2011-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-07-01	Plan is a collectively bargained plan	No
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan funding arrangement – Trust	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement - Trust	Yes
2010: CO-OP HEALTH & WELFARE PLAN AND TRUST 2010 form 5500 responses
2010-07-01	Type of plan entity	Mulitple 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 funding arrangement – Trust	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement - Trust	Yes
2009: CO-OP HEALTH & WELFARE PLAN AND TRUST 2009 form 5500 responses
2009-07-01	Type of plan entity	Mulitple employer plan
2009-07-01	Submission has been amended	No
2009-07-01	This submission is the final filing	No
2009-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-07-01	Plan is a collectively bargained plan	No
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan funding arrangement – Trust	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

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

Policy contract number

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	19
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	2324
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $137,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	3273
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

402722G

Policy instance

Insurance contract or identification number	402722G
Number of Individuals Covered	1605
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $20,302
Total amount of fees paid to insurance company	USD $10,850
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,115,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,302
Insurance broker organization code?	3
Amount paid for insurance broker fees	10850
Additional information about fees paid to insurance broker	NON-CONTINGENT COMPENSATION

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS07756

Policy instance

Insurance contract or identification number	ADDS07756
Number of Individuals Covered	1605
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $12,395
Total amount of fees paid to insurance company	USD $181
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $82,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,395
Amount paid for insurance broker fees	181
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010

Policy instance

Insurance contract or identification number	402834 0010
Number of Individuals Covered	1738
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $31,826
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $636,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,826
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

625037

Policy instance

Insurance contract or identification number	625037
Number of Individuals Covered	343
Insurance policy start date	2021-07-01
Insurance policy end date	2021-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	18
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,111
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $324
Insurance broker organization code?	3

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300047

Policy instance

Insurance contract or identification number	N000300047
Number of Individuals Covered	1
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $834
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

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	8
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $224
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84
Insurance broker organization code?	3

CANADA LIFE ASSURANCE (National Association of Insurance Commissioners NAIC id number: 80659 )

Policy contract number

03-2359

Policy instance

Insurance contract or identification number	03-2359
Number of Individuals Covered	5
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $140
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP0009064752-A

Policy instance

Insurance contract or identification number	GTP0009064752-A
Number of Individuals Covered	2900
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $2,790
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,790
Insurance broker organization code?	3

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010

Policy instance

Insurance contract or identification number	402834 0010
Number of Individuals Covered	1637
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $31,869
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $637,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,869
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS07756

Policy instance

Insurance contract or identification number	ADDS07756
Number of Individuals Covered	2117
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $13,626
Total amount of fees paid to insurance company	USD $1,007
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $90,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,626
Amount paid for insurance broker fees	1007
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

402722G

Policy instance

Insurance contract or identification number	402722G
Number of Individuals Covered	2117
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $18,850
Total amount of fees paid to insurance company	USD $17,660
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,015,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,850
Insurance broker organization code?	3
Amount paid for insurance broker fees	17660
Additional information about fees paid to insurance broker	NON-CONTINGENT COMPENSATION

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	4340
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	3131
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $201,940
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

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	24
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	22
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,445
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $428
Insurance broker organization code?	3

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300047

Policy instance

Insurance contract or identification number	N000300047
Number of Individuals Covered	1
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $834
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

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	11
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $365
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $136
Insurance broker organization code?	3

CANADA LIFE ASSURANCE (National Association of Insurance Commissioners NAIC id number: 80659 )

Policy contract number

03-2359

Policy instance

Insurance contract or identification number	03-2359
Number of Individuals Covered	6
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $164
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $164
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP0009064752-A

Policy instance

Insurance contract or identification number	GTP0009064752-A
Number of Individuals Covered	2900
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

625037

Policy instance

Insurance contract or identification number	625037
Number of Individuals Covered	227
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	21
Insurance policy start date	2021-01-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $689
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $207
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS07756

Policy instance

Insurance contract or identification number	ADDS07756
Number of Individuals Covered	2099
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $13,508
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $90,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,508
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

402722G

Policy instance

Insurance contract or identification number	402722G
Number of Individuals Covered	2099
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $18,768
Total amount of fees paid to insurance company	USD $12,469
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,108,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,768
Amount paid for insurance broker fees	12469
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	4400
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	3087
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $186,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010 SSL

Policy instance

Insurance contract or identification number	402834 0010 SSL
Number of Individuals Covered	2124
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $30,218
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $604,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,218
Insurance broker organization code?	3

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

Policy contract number

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	29
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	28
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,678
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $485
Insurance broker organization code?	3

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300047

Policy instance

Insurance contract or identification number	N000300047
Number of Individuals Covered	1
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $834
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

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	14
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $417
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $157
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP0009064752-A

Policy instance

Insurance contract or identification number	GTP0009064752-A
Number of Individuals Covered	3465
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $2,785
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,785
Insurance broker organization code?	3

CANADA LIFE ASSURANCE (National Association of Insurance Commissioners NAIC id number: 80659 )

Policy contract number

03-2359

Policy instance

Insurance contract or identification number	03-2359
Number of Individuals Covered	6
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $168
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $168
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

402722G

Policy instance

Insurance contract or identification number	402722G
Number of Individuals Covered	2142
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $18,638
Total amount of fees paid to insurance company	USD $15,881
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,099,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,638
Insurance broker organization code?	3
Amount paid for insurance broker fees	15881
Additional information about fees paid to insurance broker	NON-CONTINGENT COMPENSATION

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS07756

Policy instance

Insurance contract or identification number	ADDS07756
Number of Individuals Covered	2142
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $13,366
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $89,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,366
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	4444
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	2989
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $180,549
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

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	34
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010 SSL

Policy instance

Insurance contract or identification number	402834 0010 SSL
Number of Individuals Covered	2097
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $22,305
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $446,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,305
Insurance broker organization code?	3

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	32
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,281
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $577
Insurance broker organization code?	3

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300047

Policy instance

Insurance contract or identification number	N000300047
Number of Individuals Covered	1
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $834
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

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	16
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $530
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $198
Insurance broker organization code?	3

CANADA LIFE ASSURANCE (National Association of Insurance Commissioners NAIC id number: 80659 )

Policy contract number

03-2359

Policy instance

Insurance contract or identification number	03-2359
Number of Individuals Covered	6
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $175
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $175
Insurance broker organization code?	3

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

Policy contract number

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	48
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $34,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	38
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $2,223
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300047

Policy instance

Insurance contract or identification number	N000300047
Number of Individuals Covered	1
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $417
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

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	19
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $606
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

625037

Policy instance

Insurance contract or identification number	625037
Number of Individuals Covered	265
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

MM3125120

Policy instance

Insurance contract or identification number	MM3125120
Number of Individuals Covered	2
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CANADA LIFE ASSURANCE (National Association of Insurance Commissioners NAIC id number: 80659 )

Policy contract number

03-2359

Policy instance

Insurance contract or identification number	03-2359
Number of Individuals Covered	10
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $251
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010 SSL

Policy instance

Insurance contract or identification number	402834 0010 SSL
Number of Individuals Covered	2134
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $16,110
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $354,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS07756

Policy instance

Insurance contract or identification number	ADDS07756
Number of Individuals Covered	2157
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $13,063
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $87,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

402722G

Policy instance

Insurance contract or identification number	402722G
Number of Individuals Covered	2157
Insurance policy start date	2016-08-01
Insurance policy end date	2017-07-31
Total amount of commissions paid to insurance broker	USD $16,749
Total amount of fees paid to insurance company	USD $14,525
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $976,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	4392
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	2913
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $168,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

MM3125120

Policy instance

Insurance contract or identification number	MM3125120
Number of Individuals Covered	2
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $208
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

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	21
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $734
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $9,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $263
Insurance broker organization code?	3
Insurance broker name	ADVANCED BENEFIT SYSTEM INC

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300047

Policy instance

Insurance contract or identification number	N000300047
Number of Individuals Covered	1
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $52
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42
Insurance broker organization code?	3
Insurance broker name	M&O MARKETING INC

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	44
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $3,088
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $24,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $796
Insurance broker organization code?	3
Insurance broker name	RICHARD D HEYDEL

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

Policy contract number

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	48
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $36,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010 SSL

Policy instance

Insurance contract or identification number	402834 0010 SSL
Number of Individuals Covered	2081
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $12,905
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $322,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,905
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH BENEFITS LLC

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

ADDS07756

Policy instance

Insurance contract or identification number	ADDS07756
Number of Individuals Covered	2150
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $11,472
Total amount of fees paid to insurance company	USD $417
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $76,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,472
Amount paid for insurance broker fees	417
Additional information about fees paid to insurance broker	BONUS PAID
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

402722G

Policy instance

Insurance contract or identification number	402722G
Number of Individuals Covered	2156
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $7,379
Total amount of fees paid to insurance company	USD $6,440
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $965,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,379
Insurance broker organization code?	3
Amount paid for insurance broker fees	6440
Additional information about fees paid to insurance broker	NON-CONTINGENT COMPENSATION
Insurance broker name	MERCER HUMAN RESOURCE

CANADA LIFE ASSURANCE (National Association of Insurance Commissioners NAIC id number: 80659 )

Policy contract number

03-2359

Policy instance

Insurance contract or identification number	03-2359
Number of Individuals Covered	11
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $282
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $282
Insurance broker organization code?	3
Insurance broker name	J W RAINEY INC

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	4259
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	2534
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $136,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

625037

Policy instance

Insurance contract or identification number	625037
Number of Individuals Covered	343
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-850-290341-

Policy instance

Insurance contract or identification number	SA3-850-290341-
Number of Individuals Covered	2092
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $12,942
Total amount of fees paid to insurance company	USD $9,256
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $715,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,942
Amount paid for insurance broker fees	9256
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS

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

Policy contract number

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	25
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $826
Total amount of fees paid to insurance company	USD $88
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $292
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	BONUS AND NON-CASH INCENTIVES
Insurance broker organization code?	3
Insurance broker name	ADVANCED BENEFIT SYSTEM INC

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	4176
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	2327
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $111,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF3-850-290341-

Policy instance

Insurance contract or identification number	GF3-850-290341-
Number of Individuals Covered	1994
Insurance policy start date	2013-08-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $7,817
Total amount of fees paid to insurance company	USD $4,120
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $318,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,817
Amount paid for insurance broker fees	4120
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010 SSL

Policy instance

Insurance contract or identification number	402834 0010 SSL
Number of Individuals Covered	2071
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $12,881
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $322,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,881
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH BENEFITS LLC

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

Policy contract number

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	54
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $36,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	48
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $2,797
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $21,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $735
Insurance broker organization code?	3
Insurance broker name	RICHARD D HEYDEL

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300028/47

Policy instance

Insurance contract or identification number	N000300028/47
Number of Individuals Covered	2
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $60
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $48
Insurance broker organization code?	3
Insurance broker name	M&O MARKETING INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

625037

Policy instance

Insurance contract or identification number	625037
Number of Individuals Covered	343
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $85,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

MM3125120

Policy instance

Insurance contract or identification number	MM3125120
Number of Individuals Covered	2
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300028/47

Policy instance

Insurance contract or identification number	N000300028/47
Number of Individuals Covered	2
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $74
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59
Insurance broker organization code?	3
Insurance broker name	M&O MARKETING INC

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	53
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,554
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $27,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $933
Insurance broker organization code?	3
Insurance broker name	RICHARD D HEYDEL

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

Policy contract number

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	58
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $33,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010 SSL

Policy instance

Insurance contract or identification number	402834 0010 SSL
Number of Individuals Covered	2042
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $12,458
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $311,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,458
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH BENEFITS LLC

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-850-290341-

Policy instance

Insurance contract or identification number	SA3-850-290341-
Number of Individuals Covered	2029
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $24,855
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $665,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,855
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	4111
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	2268
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $90,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF3-850-290341-

Policy instance

Insurance contract or identification number	GF3-850-290341-
Number of Individuals Covered	1958
Insurance policy start date	2012-08-01
Insurance policy end date	2013-07-31
Total amount of commissions paid to insurance broker	USD $12,083
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $289,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,083
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS

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

Policy contract number

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	27
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $902
Total amount of fees paid to insurance company	USD $81
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $323
Insurance broker organization code?	3
Amount paid for insurance broker fees	63
Additional information about fees paid to insurance broker	BONUS & NON-CASH INCENTIVES
Insurance broker name	ADVANCED BENEFIT SYSTEM INC

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

Policy contract number

573717

Policy instance

Insurance contract or identification number	573717
Number of Individuals Covered	59
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $33,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	3536
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

SA3-850-290341-

Policy instance

Insurance contract or identification number	SA3-850-290341-
Number of Individuals Covered	1738
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $20,777
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $606,296
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,777
Insurance broker organization code?	0
Insurance broker name	MERCER HEALTH & BENEFITS

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )

Policy contract number

GF3-850-290341-

Policy instance

Insurance contract or identification number	GF3-850-290341-
Number of Individuals Covered	1643
Insurance policy start date	2011-08-01
Insurance policy end date	2012-07-31
Total amount of commissions paid to insurance broker	USD $10,231
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $247,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,231
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

625037

Policy instance

Insurance contract or identification number	625037
Number of Individuals Covered	325
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

402834 0010 SLA

Policy instance

Insurance contract or identification number	402834 0010 SLA
Number of Individuals Covered	1962
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $10,890
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $272,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,890
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH BENEFITS LLC

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

Policy contract number

U4708

Policy instance

Insurance contract or identification number	U4708
Number of Individuals Covered	55
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $3,833
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $29,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $993
Insurance broker organization code?	3
Insurance broker name	RICHARD D HEYDEL

PENN TREATY NETWORK AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63282 )

Policy contract number

N000300028/47

Policy instance

Insurance contract or identification number	N000300028/47
Number of Individuals Covered	2
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $74
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59
Insurance broker organization code?	3
Insurance broker name	M&O MARKETING INC

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	1526
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
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

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	31
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,025
Total amount of fees paid to insurance company	USD $129
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	3591
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	1478
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 137274

Policy instance

Insurance contract or identification number	GL 137274
Number of Individuals Covered	1725
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $16,971
Total amount of fees paid to insurance company	USD $5,437
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,085,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

625037

Policy instance

Insurance contract or identification number	625037
Number of Individuals Covered	101
Insurance policy start date	2010-08-01
Insurance policy end date	2011-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	1395
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
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

E7957954

Policy instance

Insurance contract or identification number	E7957954
Number of Individuals Covered	1768
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,083
Total amount of fees paid to insurance company	USD $214
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

82044

Policy instance

Insurance contract or identification number	82044
Number of Individuals Covered	3560
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 137274

Policy instance

Insurance contract or identification number	GL 137274
Number of Individuals Covered	1759
Insurance policy start date	2009-08-01
Insurance policy end date	2010-07-31
Total amount of commissions paid to insurance broker	USD $17,044
Total amount of fees paid to insurance company	USD $5,351
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,090,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	TENNESSEE FARMERS COOPERATIVE
Employer identification number (EIN):	620435104
NAIC Classification:	423990
NAIC Description:	Other Miscellaneous Durable Goods Merchant Wholesalers