401k Plan data: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN plan

EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN
Plan identification number	501

EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

EMPIRE EXPRESS, INC. has sponsored the creation of one or more 401k plans.

Company Name: EMPIRE EXPRESS, INC.

Employer identification number (EIN): 710609490

NAIC Classification: 484120
NAIC Description: General Freight Trucking, Long-Distance

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-02-01 JACKIE BUCKINGHAM 2023-08-28
501 2021-02-01 JOHN PHILLIPS 2022-08-03
501 2020-02-01 JOHN PHILLIPS 2021-07-12
501 2019-02-01 JOHN PHILLIPS 2020-06-30
501 2018-02-01 JOHN PHILLIPS 2019-08-13
501 2017-02-01
501 2016-02-01
501 2015-02-01
501 2014-02-01
501 2013-02-01
501 2012-02-01 JOHN PHILLIPS

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-02-01	JACKIE BUCKINGHAM	2023-08-28
501	2021-02-01	JOHN PHILLIPS	2022-08-03
501	2020-02-01	JOHN PHILLIPS	2021-07-12
501	2019-02-01	JOHN PHILLIPS	2020-06-30
501	2018-02-01	JOHN PHILLIPS	2019-08-13
501	2017-02-01
501	2016-02-01
501	2015-02-01
501	2014-02-01
501	2013-02-01
501	2012-02-01	JOHN PHILLIPS

Plan Statistics for EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN

Measure Date Value
2022: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-02-01 212
Total number of active participants reported on line 7a of the Form 5500 2022-02-01 222
Number of retired or separated participants receiving benefits 2022-02-01 0
Number of other retired or separated participants entitled to future benefits 2022-02-01 0
Total of all active and inactive participants 2022-02-01 222
2021: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-02-01 193
Total number of active participants reported on line 7a of the Form 5500 2021-02-01 212
Number of retired or separated participants receiving benefits 2021-02-01 0
Number of other retired or separated participants entitled to future benefits 2021-02-01 0
Total of all active and inactive participants 2021-02-01 212
2020: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-02-01 246
Total number of active participants reported on line 7a of the Form 5500 2020-02-01 193
Number of retired or separated participants receiving benefits 2020-02-01 0
Number of other retired or separated participants entitled to future benefits 2020-02-01 0
Total of all active and inactive participants 2020-02-01 193
2019: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-02-01 230
Total number of active participants reported on line 7a of the Form 5500 2019-02-01 246
Number of retired or separated participants receiving benefits 2019-02-01 87
Number of other retired or separated participants entitled to future benefits 2019-02-01 0
Total of all active and inactive participants 2019-02-01 333
2018: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-02-01 230
Total number of active participants reported on line 7a of the Form 5500 2018-02-01 230
Number of retired or separated participants receiving benefits 2018-02-01 116
Number of other retired or separated participants entitled to future benefits 2018-02-01 0
Total of all active and inactive participants 2018-02-01 346
2017: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-02-01 250
Total number of active participants reported on line 7a of the Form 5500 2017-02-01 230
Number of retired or separated participants receiving benefits 2017-02-01 0
Number of other retired or separated participants entitled to future benefits 2017-02-01 0
Total of all active and inactive participants 2017-02-01 230
2016: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-02-01 265
Total number of active participants reported on line 7a of the Form 5500 2016-02-01 250
Number of retired or separated participants receiving benefits 2016-02-01 0
Number of other retired or separated participants entitled to future benefits 2016-02-01 0
Total of all active and inactive participants 2016-02-01 250
2015: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-02-01 198
Total number of active participants reported on line 7a of the Form 5500 2015-02-01 265
Number of retired or separated participants receiving benefits 2015-02-01 0
Number of other retired or separated participants entitled to future benefits 2015-02-01 0
Total of all active and inactive participants 2015-02-01 265
2014: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-02-01 105
Total number of active participants reported on line 7a of the Form 5500 2014-02-01 198
Number of retired or separated participants receiving benefits 2014-02-01 0
Number of other retired or separated participants entitled to future benefits 2014-02-01 0
Total of all active and inactive participants 2014-02-01 198
2013: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-02-01 109
Total number of active participants reported on line 7a of the Form 5500 2013-02-01 105
Number of retired or separated participants receiving benefits 2013-02-01 0
Number of other retired or separated participants entitled to future benefits 2013-02-01 0
Total of all active and inactive participants 2013-02-01 105
2012: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-02-01 105
Total number of active participants reported on line 7a of the Form 5500 2012-02-01 109
Number of retired or separated participants receiving benefits 2012-02-01 0
Number of other retired or separated participants entitled to future benefits 2012-02-01 0
Total of all active and inactive participants 2012-02-01 109

Measure	Date	Value
2022: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-02-01	212
Total number of active participants reported on line 7a of the Form 5500	2022-02-01	222
Number of retired or separated participants receiving benefits	2022-02-01	0
Number of other retired or separated participants entitled to future benefits	2022-02-01	0
Total of all active and inactive participants	2022-02-01	222
2021: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-02-01	193
Total number of active participants reported on line 7a of the Form 5500	2021-02-01	212
Number of retired or separated participants receiving benefits	2021-02-01	0
Number of other retired or separated participants entitled to future benefits	2021-02-01	0
Total of all active and inactive participants	2021-02-01	212
2020: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-02-01	246
Total number of active participants reported on line 7a of the Form 5500	2020-02-01	193
Number of retired or separated participants receiving benefits	2020-02-01	0
Number of other retired or separated participants entitled to future benefits	2020-02-01	0
Total of all active and inactive participants	2020-02-01	193
2019: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-02-01	230
Total number of active participants reported on line 7a of the Form 5500	2019-02-01	246
Number of retired or separated participants receiving benefits	2019-02-01	87
Number of other retired or separated participants entitled to future benefits	2019-02-01	0
Total of all active and inactive participants	2019-02-01	333
2018: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-02-01	230
Total number of active participants reported on line 7a of the Form 5500	2018-02-01	230
Number of retired or separated participants receiving benefits	2018-02-01	116
Number of other retired or separated participants entitled to future benefits	2018-02-01	0
Total of all active and inactive participants	2018-02-01	346
2017: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-02-01	250
Total number of active participants reported on line 7a of the Form 5500	2017-02-01	230
Number of retired or separated participants receiving benefits	2017-02-01	0
Number of other retired or separated participants entitled to future benefits	2017-02-01	0
Total of all active and inactive participants	2017-02-01	230
2016: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-02-01	265
Total number of active participants reported on line 7a of the Form 5500	2016-02-01	250
Number of retired or separated participants receiving benefits	2016-02-01	0
Number of other retired or separated participants entitled to future benefits	2016-02-01	0
Total of all active and inactive participants	2016-02-01	250
2015: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-02-01	198
Total number of active participants reported on line 7a of the Form 5500	2015-02-01	265
Number of retired or separated participants receiving benefits	2015-02-01	0
Number of other retired or separated participants entitled to future benefits	2015-02-01	0
Total of all active and inactive participants	2015-02-01	265
2014: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-02-01	105
Total number of active participants reported on line 7a of the Form 5500	2014-02-01	198
Number of retired or separated participants receiving benefits	2014-02-01	0
Number of other retired or separated participants entitled to future benefits	2014-02-01	0
Total of all active and inactive participants	2014-02-01	198
2013: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-02-01	109
Total number of active participants reported on line 7a of the Form 5500	2013-02-01	105
Number of retired or separated participants receiving benefits	2013-02-01	0
Number of other retired or separated participants entitled to future benefits	2013-02-01	0
Total of all active and inactive participants	2013-02-01	105
2012: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-02-01	105
Total number of active participants reported on line 7a of the Form 5500	2012-02-01	109
Number of retired or separated participants receiving benefits	2012-02-01	0
Number of other retired or separated participants entitled to future benefits	2012-02-01	0
Total of all active and inactive participants	2012-02-01	109

Form 5500 Responses for EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN

2022: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-02-01	Type of plan entity	Single employer plan
2022-02-01	Submission has been amended	No
2022-02-01	This submission is the final filing	No
2022-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-02-01	Plan is a collectively bargained plan	No
2022-02-01	Plan funding arrangement – Insurance	Yes
2022-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-02-01	Plan benefit arrangement – Insurance	Yes
2022-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-02-01	Type of plan entity	Single employer plan
2021-02-01	Plan funding arrangement – Insurance	Yes
2021-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-02-01	Plan benefit arrangement – Insurance	Yes
2021-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-02-01	Type of plan entity	Single employer plan
2020-02-01	Plan funding arrangement – Insurance	Yes
2020-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-02-01	Plan benefit arrangement – Insurance	Yes
2020-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-02-01	Type of plan entity	Single employer plan
2019-02-01	Plan funding arrangement – Insurance	Yes
2019-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-02-01	Plan benefit arrangement – Insurance	Yes
2019-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-02-01	Type of plan entity	Single employer plan
2018-02-01	Plan funding arrangement – Insurance	Yes
2018-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-02-01	Plan benefit arrangement – Insurance	Yes
2018-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-02-01	Type of plan entity	Single employer plan
2017-02-01	Plan funding arrangement – Insurance	Yes
2017-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-02-01	Plan benefit arrangement – Insurance	Yes
2017-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-02-01	Type of plan entity	Single employer plan
2016-02-01	Plan funding arrangement – Insurance	Yes
2016-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-02-01	Plan benefit arrangement – Insurance	Yes
2016-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-02-01	Type of plan entity	Single employer plan
2015-02-01	Plan funding arrangement – Insurance	Yes
2015-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-02-01	Plan benefit arrangement – Insurance	Yes
2015-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-02-01	Type of plan entity	Single employer plan
2014-02-01	Plan funding arrangement – Insurance	Yes
2014-02-01	Plan benefit arrangement – Insurance	Yes
2013: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-02-01	Type of plan entity	Single employer plan
2013-02-01	Plan funding arrangement – Insurance	Yes
2013-02-01	Plan benefit arrangement – Insurance	Yes
2012: EMPIRE EXPRESS, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-02-01	Type of plan entity	Single employer plan
2012-02-01	Plan funding arrangement – Insurance	Yes
2012-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

00635667

Policy instance

Insurance contract or identification number	00635667
Number of Individuals Covered	185
Insurance policy start date	2022-02-01
Insurance policy end date	2023-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $66,410
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 $1,255,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	66410
Additional information about fees paid to insurance broker	$62,773 IN BENEFIT ADVISOR FEES AND $3,636 IN INCENTIVE COMPENSATION PAYMENTS BASED ON MEMBERSHIP
Insurance broker organization code?	3

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

Policy contract number

000010269529

Policy instance

Insurance contract or identification number	000010269529
Number of Individuals Covered	49
Insurance policy start date	2022-02-01
Insurance policy end date	2023-01-31
Total amount of commissions paid to insurance broker	USD $11,393
Total amount of fees paid to insurance company	USD $2,848
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	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 $56,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,393
Insurance broker organization code?	3
Amount paid for insurance broker fees	2848
Additional information about fees paid to insurance broker	OVERRIDES

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

Policy contract number

000400269551

Policy instance

Insurance contract or identification number	000400269551
Number of Individuals Covered	115
Insurance policy start date	2022-02-01
Insurance policy end date	2023-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $636
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 $12,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	636
Additional information about fees paid to insurance broker	OVERRIDES
Insurance broker organization code?	3

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

Policy contract number

000010269528

Policy instance

Insurance contract or identification number	000010269528
Number of Individuals Covered	256
Insurance policy start date	2022-02-01
Insurance policy end date	2023-01-31
Total amount of commissions paid to insurance broker	USD $2,399
Total amount of fees paid to insurance company	USD $600
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 $11,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,399
Insurance broker organization code?	3
Amount paid for insurance broker fees	600
Additional information about fees paid to insurance broker	OVERRIDES

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

Policy contract number

000010269530

Policy instance

Insurance contract or identification number	000010269530
Number of Individuals Covered	173
Insurance policy start date	2022-02-01
Insurance policy end date	2023-01-31
Total amount of commissions paid to insurance broker	USD $10,336
Total amount of fees paid to insurance company	USD $2,584
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	Yes
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 $51,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,336
Insurance broker organization code?	3
Amount paid for insurance broker fees	2584
Additional information about fees paid to insurance broker	OVERRIDES

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

Policy contract number

00001D041748

Policy instance

Insurance contract or identification number	00001D041748
Number of Individuals Covered	135
Insurance policy start date	2022-02-01
Insurance policy end date	2023-01-31
Total amount of commissions paid to insurance broker	USD $2,665
Total amount of fees paid to insurance company	USD $2,665
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 $53,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,665
Insurance broker organization code?	3
Amount paid for insurance broker fees	2665
Additional information about fees paid to insurance broker	OVERRIDES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

938314

Policy instance

Insurance contract or identification number	938314
Number of Individuals Covered	197
Insurance policy start date	2021-02-01
Insurance policy end date	2022-01-31
Total amount of commissions paid to insurance broker	USD $17,913
Total amount of fees paid to insurance company	USD $1,858
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $124,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,913
Amount paid for insurance broker fees	1858
Additional information about fees paid to insurance broker	BONUSES AND ADDITIONAL PAYMENTS PAID
Insurance broker organization code?	3

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

Policy contract number

0920782

Policy instance

Insurance contract or identification number	0920782
Number of Individuals Covered	254
Insurance policy start date	2021-02-01
Insurance policy end date	2022-01-31
Total amount of commissions paid to insurance broker	USD $7,561
Total amount of fees paid to insurance company	USD $52,216
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,347,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,561
Amount paid for insurance broker fees	52216
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

941179

Policy instance

Insurance contract or identification number	941179
Number of Individuals Covered	76
Insurance policy start date	2021-02-01
Insurance policy end date	2022-01-31
Total amount of commissions paid to insurance broker	USD $7,046
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $52,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,046
Insurance broker organization code?	3

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

Policy contract number

0920782

Policy instance

Insurance contract or identification number	0920782
Number of Individuals Covered	412
Insurance policy start date	2020-02-01
Insurance policy end date	2021-01-31
Total amount of commissions paid to insurance broker	USD $7,941
Total amount of fees paid to insurance company	USD $50,038
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,279,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,941
Amount paid for insurance broker fees	50038
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

938314

Policy instance

Insurance contract or identification number	938314
Number of Individuals Covered	180
Insurance policy start date	2020-02-01
Insurance policy end date	2021-01-31
Total amount of commissions paid to insurance broker	USD $20,186
Total amount of fees paid to insurance company	USD $6,845
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $155,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,186
Amount paid for insurance broker fees	6845
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

Policy instance

Number of Individuals Covered	171
Insurance policy start date	2019-02-01
Insurance policy end date	2020-01-31
Total amount of commissions paid to insurance broker	USD $32,362
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $294,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,362
Insurance broker organization code?	3

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

Policy contract number

5934779

Policy instance

Insurance contract or identification number	5934779
Number of Individuals Covered	332
Insurance policy start date	2019-02-01
Insurance policy end date	2020-01-31
Total amount of commissions paid to insurance broker	USD $8,562
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,562
Insurance broker organization code?	3

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00615634

Policy instance

Insurance contract or identification number	G00615634
Number of Individuals Covered	246
Insurance policy start date	2019-02-01
Insurance policy end date	2020-01-31
Total amount of commissions paid to insurance broker	USD $36,376
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $180,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,376
Insurance broker organization code?	3

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00615634

Policy instance

Insurance contract or identification number	G00615634
Number of Individuals Covered	230
Insurance policy start date	2018-02-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $35,737
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $177,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,722
Insurance broker organization code?	3

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

Policy contract number

TM05934779

Policy instance

Insurance contract or identification number	TM05934779
Number of Individuals Covered	347
Insurance policy start date	2018-02-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $8,348
Total amount of fees paid to insurance company	USD $291
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $81,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,521
Insurance broker organization code?	3
Amount paid for insurance broker fees	291
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

Policy instance

Number of Individuals Covered	147
Insurance policy start date	2018-02-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $29,053
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $260,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,053
Insurance broker organization code?	3

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

Policy instance

Number of Individuals Covered	145
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $24,766
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $222,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,766
Insurance broker organization code?	3
Insurance broker name	HEALTH COST SOLUTIONS, INC.

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

Policy contract number

TM05934779

Policy instance

Insurance contract or identification number	TM05934779
Number of Individuals Covered	315
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $7,005
Total amount of fees paid to insurance company	USD $1,957
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,005
Amount paid for insurance broker fees	1957
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	SIMMONS FIRST INSURANCE SERVICES

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G00615634001000

Policy instance

Insurance contract or identification number	G00615634001000
Number of Individuals Covered	230
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $24,166
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $135,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,166
Insurance broker organization code?	3
Insurance broker name	SIMMONS FIRST INSURANCE SERVICES

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1051666

Policy instance

Insurance contract or identification number	1051666
Number of Individuals Covered	71
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $8,101
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,101
Insurance broker organization code?	3
Insurance broker name	SIMMONS FIRST INSURANCE SERVICES

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1051666

Policy instance

Insurance contract or identification number	1051666
Number of Individuals Covered	194
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $12,511
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,511
Insurance broker organization code?	3
Insurance broker name	SIMMONS FIRST INSURANCE SERVICES

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1051666

Policy instance

Insurance contract or identification number	1051666
Number of Individuals Covered	379
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $4,436
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,436
Insurance broker organization code?	3
Insurance broker name	SIMMONS FIRST INSURANCE SERVICES

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

Policy instance

Number of Individuals Covered	162
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $33,660
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $302,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,660
Insurance broker organization code?	3
Insurance broker name	HEALTH COST SOLUTIONS, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30012532

Policy instance

Insurance contract or identification number	30012532
Number of Individuals Covered	134
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,209
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,209
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

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

Policy contract number

00368457

Policy instance

Insurance contract or identification number	00368457
Number of Individuals Covered	152
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $6,247
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,247
Insurance broker organization code?	3
Insurance broker name	ORMA R SMITH

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464579

Policy instance

Insurance contract or identification number	5464579
Number of Individuals Covered	73
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $12,853
Total amount of fees paid to insurance company	USD $1,905
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $64,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,853
Amount paid for insurance broker fees	1823
Additional information about fees paid to insurance broker	PRODUCER BONUS PROGRAM PAYMENTPRODUCER BONUS PROGRAM PAYMENT
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464371

Policy instance

Insurance contract or identification number	5464371
Number of Individuals Covered	204
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $16,050
Total amount of fees paid to insurance company	USD $2,473
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $80,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,050
Amount paid for insurance broker fees	2354
Additional information about fees paid to insurance broker	PRODUCER BONUS PROGRAM PAYMENT
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464580

Policy instance

Insurance contract or identification number	5464580
Number of Individuals Covered	63
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $9,526
Total amount of fees paid to insurance company	USD $1,515
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $47,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,526
Amount paid for insurance broker fees	1442
Additional information about fees paid to insurance broker	PRODUCER BONUS PROGRAM PAYMENT
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

Policy instance

Number of Individuals Covered	152
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $29,257
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $263,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,257
Insurance broker organization code?	3
Insurance broker name	HEALTH COST SOLUTIONS, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30012532

Policy instance

Insurance contract or identification number	30012532
Number of Individuals Covered	133
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,170
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,170
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

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

Policy contract number

00368457

Policy instance

Insurance contract or identification number	00368457
Number of Individuals Covered	165
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $6,333
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,333
Insurance broker organization code?	3
Insurance broker name	ORMA R SMITH

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

Policy contract number

101030

Policy instance

Insurance contract or identification number	101030
Number of Individuals Covered	191
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $39,300
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $691,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,300
Insurance broker organization code?	3
Insurance broker name	ORMA R SMITH III

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

Policy contract number

00368457

Policy instance

Insurance contract or identification number	00368457
Number of Individuals Covered	154
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $5,816
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,816
Insurance broker organization code?	3
Insurance broker name	ORMA R SMITH

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30012532

Policy instance

Insurance contract or identification number	30012532
Number of Individuals Covered	120
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $1,096
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,096
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

Policy instance

Number of Individuals Covered	118
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $5,489
Total amount of fees paid to insurance company	USD $46,121
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $49,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,489
Amount paid for insurance broker fees	46121
Insurance broker organization code?	3
Insurance broker name	HEALTH COST SOLUTIONS, INC.

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464580

Policy instance

Insurance contract or identification number	5464580
Number of Individuals Covered	61
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $10,120
Total amount of fees paid to insurance company	USD $208
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $50,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,120
Amount paid for insurance broker fees	208
Additional information about fees paid to insurance broker	NON MONETARY COMPENSATION WHICH REPRESENTS A PROPORTIONATE SHARE OF T
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464371

Policy instance

Insurance contract or identification number	5464371
Number of Individuals Covered	198
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $15,721
Total amount of fees paid to insurance company	USD $366
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $78,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,721
Amount paid for insurance broker fees	366
Additional information about fees paid to insurance broker	NON MONETARY COMPENSATION WHICH REPRESENTS A PROPORTIONATE SHARE OF T
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464579

Policy instance

Insurance contract or identification number	5464579
Number of Individuals Covered	80
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $13,851
Total amount of fees paid to insurance company	USD $286
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $69,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,851
Amount paid for insurance broker fees	286
Additional information about fees paid to insurance broker	NON MONETARY COMPENSATION WHICH REPRESENTS A PROPORTIONATE SHARE OF T
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

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

Policy contract number

101030

Policy instance

Insurance contract or identification number	101030
Number of Individuals Covered	189
Insurance policy start date	2012-02-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $33,879
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $617,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,879
Insurance broker organization code?	3
Insurance broker name	ORMA SMITH

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

Policy contract number

00368457

Policy instance

Insurance contract or identification number	00368457
Number of Individuals Covered	149
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $5,750
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $63,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,740
Insurance broker organization code?	3
Insurance broker name	JAMES MICHAEL SEGO

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30012532

Policy instance

Insurance contract or identification number	30012532
Number of Individuals Covered	117
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,095
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,095
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

Policy instance

Number of Individuals Covered	110
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $5,345
Total amount of fees paid to insurance company	USD $43,333
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $48,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,345
Amount paid for insurance broker fees	43333
Insurance broker organization code?	3
Insurance broker name	HEALTH COST SOLUTIONS, INC.

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464371

Policy instance

Insurance contract or identification number	5464371
Number of Individuals Covered	185
Insurance policy start date	2012-09-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $6,449
Total amount of fees paid to insurance company	USD $1,442
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $32,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,449
Amount paid for insurance broker fees	1442
Additional information about fees paid to insurance broker	PRODUCER BONUS PROGRAM PAYMENT
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464580

Policy instance

Insurance contract or identification number	5464580
Number of Individuals Covered	62
Insurance policy start date	2012-09-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $4,141
Total amount of fees paid to insurance company	USD $973
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,141
Amount paid for insurance broker fees	973
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5464579

Policy instance

Insurance contract or identification number	5464579
Number of Individuals Covered	82
Insurance policy start date	2012-09-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $5,764
Total amount of fees paid to insurance company	USD $1,359
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $28,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,764
Amount paid for insurance broker fees	1359
Insurance broker organization code?	3
Insurance broker name	FIRST STATE INSURANCE LLC

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

Policy contract number

GL144152

Policy instance

Insurance contract or identification number	GL144152
Number of Individuals Covered	172
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,609
Total amount of fees paid to insurance company	USD $198
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	BASIC AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )

Policy contract number

Policy instance

Number of Individuals Covered	109
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $5,636
Total amount of fees paid to insurance company	USD $42,275
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $50,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30012532

Policy instance

Insurance contract or identification number	30012532
Number of Individuals Covered	119
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,099
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00368457

Policy instance

Insurance contract or identification number	00368457
Number of Individuals Covered	146
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $5,620
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,831
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

101030

Policy instance

Insurance contract or identification number	101030
Number of Individuals Covered	200
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $38,627
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $567,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	EMPIRE EXPRESS, INC.
Employer identification number (EIN):	710609490
NAIC Classification:	484120
NAIC Description:	General Freight Trucking, Long-Distance