401k Plan data: MARTIN GOTTLIEB & ASSOCIATES, LLC plan

MARTIN GOTTLIEB & ASSOCIATES, LLC 401k Plan overview

Plan Name	MARTIN GOTTLIEB & ASSOCIATES, LLC
Plan identification number	502

MARTIN GOTTLIEB & ASSOCIATES, LLC 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

401k Sponsoring company profile

MARTIN GOTTLIEB & ASSOCIATES LLC has sponsored the creation of one or more 401k plans.

Company Name: MARTIN GOTTLIEB & ASSOCIATES LLC

Employer identification number (EIN): 651226340

NAIC Classification: 541990
NAIC Description: All Other Professional, Scientific, and Technical Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MARTIN GOTTLIEB & ASSOCIATES, LLC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2017-01-01 JAMES DRINKWATER
502 2016-01-01 JAMES DRINKWATER
502 2015-01-01 JAMES M. DRINKWATER
502 2014-01-01 JAMES M. DRINKWATER
502 2013-01-01 JAMES D. DRINKWATER
502 2012-01-01 JAMES D. DRINKWATER
502 2011-01-01 JAMES D DRINKWATER
502 2009-01-01 JAMES D DRINKWATER

Plan id#	Filing Submission Date	Name of Administrator
502	2017-01-01	JAMES DRINKWATER
502	2016-01-01	JAMES DRINKWATER
502	2015-01-01	JAMES M. DRINKWATER
502	2014-01-01	JAMES M. DRINKWATER
502	2013-01-01	JAMES D. DRINKWATER
502	2012-01-01	JAMES D. DRINKWATER
502	2011-01-01	JAMES D DRINKWATER
502	2009-01-01	JAMES D DRINKWATER

Plan Statistics for MARTIN GOTTLIEB & ASSOCIATES, LLC

401k plan membership statisitcs for MARTIN GOTTLIEB & ASSOCIATES, LLC

Measure Date Value
2017: MARTIN GOTTLIEB & ASSOCIATES, LLC 2017 401k membership
Total participants, beginning-of-year 2017-01-01 356
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 353
Number of retired or separated participants receiving benefits 2017-01-01 3
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 356
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 356
2016: MARTIN GOTTLIEB & ASSOCIATES, LLC 2016 401k membership
Total participants, beginning-of-year 2016-01-01 287
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 256
Total of all active and inactive participants 2016-01-01 256
Total participants 2016-01-01 256
2015: MARTIN GOTTLIEB & ASSOCIATES, LLC 2015 401k membership
Total participants, beginning-of-year 2015-01-01 242
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 287
Total of all active and inactive participants 2015-01-01 287
Total participants 2015-01-01 0
2014: MARTIN GOTTLIEB & ASSOCIATES, LLC 2014 401k membership
Total participants, beginning-of-year 2014-01-01 242
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 242
Total of all active and inactive participants 2014-01-01 242
Total participants 2014-01-01 0
2013: MARTIN GOTTLIEB & ASSOCIATES, LLC 2013 401k membership
Total participants, beginning-of-year 2013-01-01 194
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 242
Total of all active and inactive participants 2013-01-01 242
Total participants 2013-01-01 0
2012: MARTIN GOTTLIEB & ASSOCIATES, LLC 2012 401k membership
Total participants, beginning-of-year 2012-01-01 124
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 194
Total of all active and inactive participants 2012-01-01 194
Total participants 2012-01-01 0
2011: MARTIN GOTTLIEB & ASSOCIATES, LLC 2011 401k membership
Total participants, beginning-of-year 2011-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 124
Total of all active and inactive participants 2011-01-01 124
Total participants 2011-01-01 124
2009: MARTIN GOTTLIEB & ASSOCIATES, LLC 2009 401k membership
Total participants, beginning-of-year 2009-01-01 149
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 149
Total of all active and inactive participants 2009-01-01 149
Total participants 2009-01-01 149

Measure	Date	Value
2017: MARTIN GOTTLIEB & ASSOCIATES, LLC 2017 401k membership
Total participants, beginning-of-year	2017-01-01	356
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	353
Number of retired or separated participants receiving benefits	2017-01-01	3
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	356
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	356
2016: MARTIN GOTTLIEB & ASSOCIATES, LLC 2016 401k membership
Total participants, beginning-of-year	2016-01-01	287
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	256
Total of all active and inactive participants	2016-01-01	256
Total participants	2016-01-01	256
2015: MARTIN GOTTLIEB & ASSOCIATES, LLC 2015 401k membership
Total participants, beginning-of-year	2015-01-01	242
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	287
Total of all active and inactive participants	2015-01-01	287
Total participants	2015-01-01	0
2014: MARTIN GOTTLIEB & ASSOCIATES, LLC 2014 401k membership
Total participants, beginning-of-year	2014-01-01	242
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	242
Total of all active and inactive participants	2014-01-01	242
Total participants	2014-01-01	0
2013: MARTIN GOTTLIEB & ASSOCIATES, LLC 2013 401k membership
Total participants, beginning-of-year	2013-01-01	194
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	242
Total of all active and inactive participants	2013-01-01	242
Total participants	2013-01-01	0
2012: MARTIN GOTTLIEB & ASSOCIATES, LLC 2012 401k membership
Total participants, beginning-of-year	2012-01-01	124
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	194
Total of all active and inactive participants	2012-01-01	194
Total participants	2012-01-01	0
2011: MARTIN GOTTLIEB & ASSOCIATES, LLC 2011 401k membership
Total participants, beginning-of-year	2011-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	124
Total of all active and inactive participants	2011-01-01	124
Total participants	2011-01-01	124
2009: MARTIN GOTTLIEB & ASSOCIATES, LLC 2009 401k membership
Total participants, beginning-of-year	2009-01-01	149
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	149
Total of all active and inactive participants	2009-01-01	149
Total participants	2009-01-01	149

Form 5500 Responses for MARTIN GOTTLIEB & ASSOCIATES, LLC

2017: MARTIN GOTTLIEB & ASSOCIATES, LLC 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: MARTIN GOTTLIEB & ASSOCIATES, LLC 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: MARTIN GOTTLIEB & ASSOCIATES, LLC 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: MARTIN GOTTLIEB & ASSOCIATES, LLC 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: MARTIN GOTTLIEB & ASSOCIATES, LLC 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: MARTIN GOTTLIEB & ASSOCIATES, LLC 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: MARTIN GOTTLIEB & ASSOCIATES, LLC 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: MARTIN GOTTLIEB & ASSOCIATES, LLC 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

880214G

Policy instance

Insurance contract or identification number	880214G
Insurance policy start date	2017-02-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $10,410
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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 $52,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,410
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

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

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
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?	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?	Yes

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

Policy contract number

E4601027

Policy instance

Insurance contract or identification number	E4601027
Number of Individuals Covered	1
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $1
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 & CANCER
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 $18
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MACDOUGALL BENEFITS LLC

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

Policy contract number

E4601027

Policy instance

Insurance contract or identification number	E4601027
Number of Individuals Covered	249
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $2,333
Total amount of fees paid to insurance company	USD $209
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT & CANCER
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 $12,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $83
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

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

Policy contract number

0200069

Policy instance

Insurance contract or identification number	0200069
Number of Individuals Covered	156
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,099
Total amount of fees paid to insurance company	USD $437
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	CRITICAL ILLNESS
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 $38,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	355
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

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

Policy contract number

0200070

Policy instance

Insurance contract or identification number	0200070
Number of Individuals Covered	244
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,368
Total amount of fees paid to insurance company	USD $250
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	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 $18,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	168
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

35913

Policy instance

Insurance contract or identification number	35913
Number of Individuals Covered	483
Insurance policy start date	2017-02-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,368
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	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 $26,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,368
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	HYLANT GROUP INC

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

Policy contract number

025598

Policy instance

Insurance contract or identification number	025598
Number of Individuals Covered	119
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $3,358
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,358
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

559947

Policy instance

Insurance contract or identification number	559947
Number of Individuals Covered	195
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,121
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,121
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025597

Policy instance

Insurance contract or identification number	025597
Number of Individuals Covered	10
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $803
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $803
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

215L14

Policy instance

Insurance contract or identification number	215L14
Number of Individuals Covered	198
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of fees paid to insurance company	USD $12,377
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $124,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12377
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

INDIVIDUAL HI

Policy instance

Insurance contract or identification number	INDIVIDUAL HI
Number of Individuals Covered	18
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $154
Other welfare benefits provided	INDIVIDUAL HI
Welfare Benefit Premiums Paid to Carrier	USD $4,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $154
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	184
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $3,603
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,771
Insurance broker organization code?	3
Insurance broker name	AMERICAN FIDELITY ASSURANCE COMPANY

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

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	194
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $39,107
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid in cash?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,107
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	153
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $987
Other welfare benefits provided	ACCIDENT ONLY
Welfare Benefit Premiums Paid to Carrier	USD $18,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,146
Insurance broker organization code?	3
Insurance broker name	AMERICAN FIDELITY ASSURANCE COMPANY

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

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	63
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $1,173
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $17,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,261
Insurance broker organization code?	3
Insurance broker name	AMERICAN FIDELITY ASSURANCE COMPANY

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	287
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of fees paid to insurance company	USD $1,128
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1128
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025599

Policy instance

Insurance contract or identification number	025599
Number of Individuals Covered	103
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $3,501
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $23,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,501
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	136
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $1,058
Other welfare benefits provided	ACCIDENT ONLY
Welfare Benefit Premiums Paid to Carrier	USD $18,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,014
Insurance broker organization code?	3
Insurance broker name	AMERICAN FIDELITY ASSURANCE COMPANY

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

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	171
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $37,419
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,419
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025599

Policy instance

Insurance contract or identification number	025599
Number of Individuals Covered	93
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $2,624
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,624
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025598

Policy instance

Insurance contract or identification number	025598
Number of Individuals Covered	89
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $2,957
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,957
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025597

Policy instance

Insurance contract or identification number	025597
Number of Individuals Covered	10
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $799
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $799
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	153
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $3,718
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,323
Insurance broker organization code?	3
Insurance broker name	AMERICAN FIDELITY ASSURANCE COMPANY

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

Policy contract number

559947

Policy instance

Insurance contract or identification number	559947
Number of Individuals Covered	156
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of fees paid to insurance company	USD $1,764
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1764
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	242
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of fees paid to insurance company	USD $588
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	588
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

25E0752

Policy instance

Insurance contract or identification number	25E0752
Number of Individuals Covered	186
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of fees paid to insurance company	USD $11,954
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $119,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	11954
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	59
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $1,218
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $17,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,039
Insurance broker organization code?	3
Insurance broker name	AMERICAN FIDELITY ASSURANCE COMPANY

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

Policy contract number

INDIVIDUAL HI

Policy instance

Insurance contract or identification number	INDIVIDUAL HI
Number of Individuals Covered	19
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $164
Other welfare benefits provided	INDIVIDUAL HI
Welfare Benefit Premiums Paid to Carrier	USD $4,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $121
Insurance broker organization code?	3
Insurance broker name	MARGOL, ESTATE OF OREN D

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

25E0752

Policy instance

Insurance contract or identification number	25E0752
Number of Individuals Covered	183
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of fees paid to insurance company	USD $9,547
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9547
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025597

Policy instance

Insurance contract or identification number	025597
Number of Individuals Covered	10
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $806
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $806
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025598

Policy instance

Insurance contract or identification number	025598
Number of Individuals Covered	87
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $2,775
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,775
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025599

Policy instance

Insurance contract or identification number	025599
Number of Individuals Covered	66
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $2,313
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $15,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,313
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	163
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $31,816
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,816
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	124
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $2,413
Other welfare benefits provided	ACCIDENT ONLY
Welfare Benefit Premiums Paid to Carrier	USD $14,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,715
Insurance broker organization code?	0
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

INDIVIDUAL HI

Policy instance

Insurance contract or identification number	INDIVIDUAL HI
Number of Individuals Covered	19
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $186
Other welfare benefits provided	INDIVIDUAL HI
Welfare Benefit Premiums Paid to Carrier	USD $4,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $171
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	168
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $5,168
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,487
Insurance broker organization code?	0
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

559947

Policy instance

Insurance contract or identification number	559947
Number of Individuals Covered	143
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,814
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,814
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	242
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of fees paid to insurance company	USD $508
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	508
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	71
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $1,810
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $16,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $850
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025599

Policy instance

Insurance contract or identification number	025599
Number of Individuals Covered	66
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $2,140
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,140
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	120
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $25,224
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,224
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

840628-000-099

Policy instance

Insurance contract or identification number	840628-000-099
Number of Individuals Covered	122
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $8,654
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,654
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	110
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $1,066
Other welfare benefits provided	ACCIDENT ONLY
Welfare Benefit Premiums Paid to Carrier	USD $11,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $459
Insurance broker organization code?	0
Insurance broker name	MARGOL, OREN

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

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	63
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $2,320
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $13,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $928
Insurance broker organization code?	3
Insurance broker name	AMERICAN FIDELITY ASSURANCE COMPANY

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

Policy contract number

INDIVIDUAL HI

Policy instance

Insurance contract or identification number	INDIVIDUAL HI
Number of Individuals Covered	19
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $276
Other welfare benefits provided	INDIVIDUAL HI
Welfare Benefit Premiums Paid to Carrier	USD $5,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38
Insurance broker organization code?	0
Insurance broker name	MARGOL, OREN

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

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	141
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $4,163
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,830
Insurance broker organization code?	0
Insurance broker name	MARGOL, OREN

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

Policy contract number

559947

Policy instance

Insurance contract or identification number	559947
Number of Individuals Covered	126
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,310
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,310
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025598

Policy instance

Insurance contract or identification number	025598
Number of Individuals Covered	90
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $2,377
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,377
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025597

Policy instance

Insurance contract or identification number	025597
Number of Individuals Covered	10
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $962
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $962
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	194
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of fees paid to insurance company	USD $406
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	406
Additional information about fees paid to insurance broker	SERVICE FEES
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

840628-000-099

Policy instance

Insurance contract or identification number	840628-000-099
Number of Individuals Covered	124
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $7,167
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	99
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $19,708
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid in cash?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

025599

Policy instance

Insurance contract or identification number	025599
Number of Individuals Covered	48
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $2,032
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,360
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

025598

Policy instance

Insurance contract or identification number	025598
Number of Individuals Covered	69
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $1,867
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,239
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

025597

Policy instance

Insurance contract or identification number	025597
Number of Individuals Covered	11
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $1,513
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Number of Individuals Covered	34
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $332
Other welfare benefits provided	ACCIDENT ONLY
Welfare Benefit Premiums Paid to Carrier	USD $5,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	31
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $740
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $9,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

INDIVIDUAL HI

Policy instance

Insurance contract or identification number	INDIVIDUAL HI
Number of Individuals Covered	14
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $238
Other welfare benefits provided	INDIVIDUAL HI
Welfare Benefit Premiums Paid to Carrier	USD $5,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

559947

Policy instance

Insurance contract or identification number	559947
Number of Individuals Covered	111
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,037
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	113
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $1,951
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,746
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

025597

Policy instance

Insurance contract or identification number	025597
Number of Individuals Covered	153
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,470
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,470
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

559947

Policy instance

Insurance contract or identification number	559947
Number of Individuals Covered	93
Insurance policy start date	2010-04-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $733
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $733
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

STD

Policy instance

Insurance contract or identification number	STD
Number of Individuals Covered	114
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $1,877
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,877
Insurance broker organization code?	3
Insurance broker name	MARGOL, OREN

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

Policy contract number

INDIVIDUAL HI

Policy instance

Insurance contract or identification number	INDIVIDUAL HI
Number of Individuals Covered	15
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $259
Other welfare benefits provided	INDIVIDUAL HI
Welfare Benefit Premiums Paid to Carrier	USD $6,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $259
Insurance broker organization code?	3
Insurance broker name	MARGOL, OREN

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

Policy contract number

CANCER

Policy instance

Insurance contract or identification number	CANCER
Number of Individuals Covered	23
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $746
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $8,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $746
Insurance broker organization code?	3
Insurance broker name	MARGOL, OREN

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

Policy contract number

ACCIDENT ONLY

Policy instance

Insurance contract or identification number	ACCIDENT ONLY
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $111
Other welfare benefits provided	ACCIDENT ONLY
Welfare Benefit Premiums Paid to Carrier	USD $1,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $111
Insurance broker organization code?	3
Insurance broker name	MARGOL, OREN

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

Policy contract number

61874

Policy instance

Insurance contract or identification number	61874
Number of Individuals Covered	86
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $20,867
Health Insurance Welfare Benefit	Yes
Were dividends or retroactive rate refunds paid in cash?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,867
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025599

Policy instance

Insurance contract or identification number	025599
Number of Individuals Covered	41
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $1,898
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFESTYLE AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,898
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

025598

Policy instance

Insurance contract or identification number	025598
Number of Individuals Covered	55
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $1,630
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,630
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

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

Policy contract number

840628-000-099

Policy instance

Insurance contract or identification number	840628-000-099
Number of Individuals Covered	113
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $6,714
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $66,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,714
Insurance broker organization code?	3
Insurance broker name	VANDROFF INSURANCE AGENCY

Potentially related plans

MARTIN GOTTLIEB & ASSOCIATES LLC 401(K) PROFIT SHARING PLAN [EIN = 352579202]

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Company Name:	MARTIN GOTTLIEB & ASSOCIATES LLC
Employer identification number (EIN):	651226340
NAIC Classification:	541990
NAIC Description:	All Other Professional, Scientific, and Technical Services