401k Plan data: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN plan

WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN
Plan identification number	501

WAREHOUSE MARKET, INC. EMPLOYEE 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

WAREHOUSE MARKET, INC. has sponsored the creation of one or more 401k plans.

Company Name: WAREHOUSE MARKET, INC.

Employer identification number (EIN): 730501598

NAIC Classification: 445110
NAIC Description: Supermarkets and Other Grocery (except Convenience) Stores

Additional information about WAREHOUSE MARKET, INC.

Jurisdiction of Incorporation: Wyoming Corporations Division

Incorporation Date: 1968-06-27

Company Identification Number: 000103248

Legal Registered Office Address: 1062 Brundage Ln

Sheridan
United States of America (USA)
82801

More information about WAREHOUSE MARKET, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 JAMES R. BROWN JAMES R. BROWN 2019-07-19
501 2017-01-01 JAMES R. BROWN, PRESIDENTCEO
501 2016-01-01 ANN WINKLE, ASST. SECRETARY
501 2015-01-01 ANN WINKLE, ASST. SECRETARY
501 2014-01-01 ANN WINKLE, ASST. SECRETARY
501 2013-01-01 ANN WINKLE, ASST. SECRETARY
501 2012-01-01 ANN WINKLE, ASST. SECRETARY
501 2011-01-01 ANN WINKLE ASST SECRETARY
501 2009-01-01 ANN WINKLE ASST SECRETARY

Plan Statistics for WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2020: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 181
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 86
Number of retired or separated participants receiving benefits 2020-01-01 1
Total of all active and inactive participants 2020-01-01 87
2019: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 182
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 180
Number of retired or separated participants receiving benefits 2019-01-01 1
Total of all active and inactive participants 2019-01-01 181
2018: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 227
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 180
Number of retired or separated participants receiving benefits 2018-01-01 2
Total of all active and inactive participants 2018-01-01 182
2017: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 304
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 225
Number of retired or separated participants receiving benefits 2017-01-01 2
Total of all active and inactive participants 2017-01-01 227
Total participants 2017-01-01 227
2016: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 322
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 302
Number of retired or separated participants receiving benefits 2016-01-01 2
Total of all active and inactive participants 2016-01-01 304
Total participants 2016-01-01 304
2015: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 323
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 322
Number of retired or separated participants receiving benefits 2015-01-01 1
Total of all active and inactive participants 2015-01-01 323
Total participants 2015-01-01 0
2014: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 279
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 322
Number of retired or separated participants receiving benefits 2014-01-01 1
Total of all active and inactive participants 2014-01-01 323
Total participants 2014-01-01 0
2013: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 279
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 278
Number of retired or separated participants receiving benefits 2013-01-01 1
Total of all active and inactive participants 2013-01-01 279
Total participants 2013-01-01 0
2012: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 296
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 295
Number of retired or separated participants receiving benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 296
Total participants 2012-01-01 0
2011: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 305
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 295
Number of retired or separated participants receiving benefits 2011-01-01 1
Total of all active and inactive participants 2011-01-01 296
Total participants 2011-01-01 296
2009: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 296
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 293
Number of retired or separated participants receiving benefits 2009-01-01 3
Total of all active and inactive participants 2009-01-01 296
Total participants 2009-01-01 296

Measure	Date	Value
2020: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	181
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	86
Number of retired or separated participants receiving benefits	2020-01-01	1
Total of all active and inactive participants	2020-01-01	87
2019: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	182
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	180
Number of retired or separated participants receiving benefits	2019-01-01	1
Total of all active and inactive participants	2019-01-01	181
2018: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	227
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	180
Number of retired or separated participants receiving benefits	2018-01-01	2
Total of all active and inactive participants	2018-01-01	182
2017: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	304
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	225
Number of retired or separated participants receiving benefits	2017-01-01	2
Total of all active and inactive participants	2017-01-01	227
Total participants	2017-01-01	227
2016: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	322
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	302
Number of retired or separated participants receiving benefits	2016-01-01	2
Total of all active and inactive participants	2016-01-01	304
Total participants	2016-01-01	304
2015: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	323
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	322
Number of retired or separated participants receiving benefits	2015-01-01	1
Total of all active and inactive participants	2015-01-01	323
Total participants	2015-01-01	0
2014: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	279
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	322
Number of retired or separated participants receiving benefits	2014-01-01	1
Total of all active and inactive participants	2014-01-01	323
Total participants	2014-01-01	0
2013: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	279
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	278
Number of retired or separated participants receiving benefits	2013-01-01	1
Total of all active and inactive participants	2013-01-01	279
Total participants	2013-01-01	0
2012: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	296
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	295
Number of retired or separated participants receiving benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	296
Total participants	2012-01-01	0
2011: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	305
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	295
Number of retired or separated participants receiving benefits	2011-01-01	1
Total of all active and inactive participants	2011-01-01	296
Total participants	2011-01-01	296
2009: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	296
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	293
Number of retired or separated participants receiving benefits	2009-01-01	3
Total of all active and inactive participants	2009-01-01	296
Total participants	2009-01-01	296

Form 5500 Responses for WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN

2020: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
2020-01-01	This submission is the final filing	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
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: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
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: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 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: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 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: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 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: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 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: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 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: WAREHOUSE MARKET, INC. EMPLOYEE BENEFIT PLAN 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

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

Policy contract number

924426

Policy instance

Insurance contract or identification number	924426
Number of Individuals Covered	84
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,526
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D CRITICAL ILLNESS CANCER
Welfare Benefit Premiums Paid to Carrier	USD $55,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,352
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	27
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,534
Total amount of fees paid to insurance company	USD $4,384
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,534
Amount paid for insurance broker fees	4384

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 10001 )

Policy contract number

C11293

Policy instance

Insurance contract or identification number	C11293
Number of Individuals Covered	87
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $39,760
Welfare Benefit Premiums Paid to Carrier	USD $339,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	39760
Insurance broker organization code?	3

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 10001 )

Policy contract number

C11293

Policy instance

Insurance contract or identification number	C11293
Number of Individuals Covered	181
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $58,205
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $565,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,205
Insurance broker organization code?	3

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	107
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,446
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,446
Insurance broker organization code?	3

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

Policy contract number

356454G

Policy instance

Insurance contract or identification number	356454G
Number of Individuals Covered	57
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $59
Total amount of fees paid to insurance company	USD $0
Long Term Disability 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 $59
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	9
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $600
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $600
Insurance broker organization code?	3

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	20
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,534
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $8,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,534
Insurance broker organization code?	3

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	16
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,736
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $5,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,736
Insurance broker organization code?	3

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

Policy contract number

924426

Policy instance

Insurance contract or identification number	924426
Number of Individuals Covered	197
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,963
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
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 $51,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,963
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	62
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,728
Total amount of fees paid to insurance company	USD $7,471
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,728
Amount paid for insurance broker fees	7471

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	129
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,888
Total amount of fees paid to insurance company	USD $295
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,888
Insurance broker organization code?	3
Amount paid for insurance broker fees	295

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 10001 )

Policy contract number

C11293

Policy instance

Insurance contract or identification number	C11293
Number of Individuals Covered	182
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $70,315
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $728,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70,315
Insurance broker organization code?	3

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

Policy contract number

12109979

Policy instance

Insurance contract or identification number	12109979
Number of Individuals Covered	136
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,200
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,200
Insurance broker organization code?	3

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	308
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,628
Total amount of fees paid to insurance company	USD $635
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $36,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,628
Amount paid for insurance broker fees	55
Insurance broker organization code?	3

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

Policy contract number

356454G

Policy instance

Insurance contract or identification number	356454G
Number of Individuals Covered	22
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,759
Total amount of fees paid to insurance company	USD $189
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,759
Insurance broker organization code?	3
Amount paid for insurance broker fees	189
Additional information about fees paid to insurance broker	BONUS

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	86
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,081
Total amount of fees paid to insurance company	USD $8,778
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,081
Amount paid for insurance broker fees	8778

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	4
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $198
Total amount of fees paid to insurance company	USD $19
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $198
Insurance broker organization code?	3
Amount paid for insurance broker fees	19

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	68
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $10,915
Total amount of fees paid to insurance company	USD $1,222
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $36,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,915
Amount paid for insurance broker fees	1222
Insurance broker organization code?	3

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	61
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $9,807
Total amount of fees paid to insurance company	USD $1,174
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $32,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,807
Amount paid for insurance broker fees	1174
Insurance broker organization code?	3

WASHINGTON NATIONAL INSURANCE (National Association of Insurance Commissioners NAIC id number: 78174 )

Policy contract number

30334

Policy instance

Insurance contract or identification number	30334
Number of Individuals Covered	31
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,700
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $8,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $899
Insurance broker organization code?	3
Insurance broker name	CAPITAL AMERICAN LIFE INS CO.

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

Policy contract number

83076809

Policy instance

Insurance contract or identification number	83076809
Number of Individuals Covered	32
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,281
Total amount of fees paid to insurance company	USD $59
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,836
Insurance broker organization code?	3
Amount paid for insurance broker fees	59
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	GALLAGHER BENEFIT SVCS INC

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

Policy contract number

12109979

Policy instance

Insurance contract or identification number	12109979
Number of Individuals Covered	158
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,456
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,128
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LIMITED

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

IIAS9960-7608-1

Policy instance

Insurance contract or identification number	IIAS9960-7608-1
Number of Individuals Covered	173
Insurance policy start date	2017-01-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $17,170
Total amount of fees paid to insurance company	USD $75,552
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $148,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	37160
Additional information about fees paid to insurance broker	MEDICAL ADMIN FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $17,170
Insurance broker name	RESOURCEONE ADMINISTRATORS

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	365
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,726
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,211
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	365
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $98
Total amount of fees paid to insurance company	USD $70
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89
Insurance broker organization code?	3
Amount paid for insurance broker fees	70
Insurance broker name	HUB INTERNATIONAL

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	143
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,212
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,747
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $206
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $127
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	84
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,070
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $6,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,070
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 10001 )

Policy contract number

C11293

Policy instance

Insurance contract or identification number	C11293
Number of Individuals Covered	227
Insurance policy start date	2017-11-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,125
Welfare Benefit Premiums Paid to Carrier	USD $72,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,125
Insurance broker name	HUB INTERNATIONAL MID-AMERICA

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

Policy contract number

5473006

Policy instance

Insurance contract or identification number	5473006
Number of Individuals Covered	77
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-01
Total amount of commissions paid to insurance broker	USD $1,876
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $6,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,876
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

IIAS9960-7608-1

Policy instance

Insurance contract or identification number	IIAS9960-7608-1
Number of Individuals Covered	267
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,312
Total amount of fees paid to insurance company	USD $98,096
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $195,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	47759
Additional information about fees paid to insurance broker	MEDICAL ADMIN FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $6,312
Insurance broker name	MEDCAREONE

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	321
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $110
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $110
Insurance broker organization code?	3
Insurance broker name	JB SOLUTIONS LLC

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	331
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,289
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,289
Insurance broker organization code?	3
Insurance broker name	JB SOLUTIONS LLC

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

Policy contract number

ADD-S06289

Policy instance

Insurance contract or identification number	ADD-S06289
Number of Individuals Covered	114
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,504
Total amount of fees paid to insurance company	USD $322
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $10,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,504
Insurance broker organization code?	3
Amount paid for insurance broker fees	322
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	GALLAGHER BENEFIT SERV INC.

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	4
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $282
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $282
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	206
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,844
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,844
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

WASHINGTON NATIONAL INSURANCE (National Association of Insurance Commissioners NAIC id number: 78174 )

Policy contract number

30334

Policy instance

Insurance contract or identification number	30334
Number of Individuals Covered	41
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,161
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $12,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,134
Insurance broker organization code?	3
Insurance broker name	CAPITAL AMERICAN LIFE INS CO.

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

Policy contract number

356454G

Policy instance

Insurance contract or identification number	356454G
Number of Individuals Covered	53
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,070
Total amount of fees paid to insurance company	USD $411
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,070
Insurance broker organization code?	3
Amount paid for insurance broker fees	411
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	GALLAGHER BENEFIT SVCS INC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

12109979

Policy instance

Insurance contract or identification number	12109979
Number of Individuals Covered	209
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,554
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,554
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON, INC

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	322
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,841
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,841
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

WASHINGTON NATIONAL INSURANCE (National Association of Insurance Commissioners NAIC id number: 78174 )

Policy contract number

30334

Policy instance

Insurance contract or identification number	30334
Number of Individuals Covered	64
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,373
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $14,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,239
Insurance broker organization code?	3
Insurance broker name	CAPITAL AMERICAN LIFE INS CO.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

12109979

Policy instance

Insurance contract or identification number	12109979
Number of Individuals Covered	214
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,443
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,443
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON, INC

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

IIAS9960-7608-1

Policy instance

Insurance contract or identification number	IIAS9960-7608-1
Number of Individuals Covered	265
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,144
Total amount of fees paid to insurance company	USD $95,355
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $183,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	43776
Additional information about fees paid to insurance broker	MEDICAL ADMIN FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $6,144
Insurance broker name	RESOURCEONE ADMINISTRATORS

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	455
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $105
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $1,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $105
Insurance broker organization code?	3
Insurance broker name	JB SOLUTIONS LLC

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	6
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $222
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $222
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	377
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,828
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $68,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,828
Insurance broker organization code?	3
Insurance broker name	JB SOLUTIONS LLC

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

Policy contract number

356454G

Policy instance

Insurance contract or identification number	356454G
Number of Individuals Covered	51
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,400
Total amount of fees paid to insurance company	USD $596
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,400
Insurance broker organization code?	3
Amount paid for insurance broker fees	596
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	GALLAGHER BENEFIT SVCS INC

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

Policy contract number

ADD-S06289

Policy instance

Insurance contract or identification number	ADD-S06289
Number of Individuals Covered	110
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,533
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $10,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,533
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SVCS INC

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

IIAS9960-7608-1

Policy instance

Insurance contract or identification number	IIAS9960-7608-1
Number of Individuals Covered	247
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,080
Total amount of fees paid to insurance company	USD $91,614
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $187,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	41403
Additional information about fees paid to insurance broker	MEDICAL ADMIN FEES
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $6,080
Insurance broker name	RESOURCEONE ADMINISTRATORS

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

Policy contract number

ADD-S06289

Policy instance

Insurance contract or identification number	ADD-S06289
Number of Individuals Covered	100
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,589
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $10,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,589
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SVCS INC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

12109979

Policy instance

Insurance contract or identification number	12109979
Number of Individuals Covered	197
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,454
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,454
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON, INC

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	208
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,251
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,251
Insurance broker organization code?	3
Insurance broker name	JB SOLUTIONS LLC

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

Policy contract number

356454G

Policy instance

Insurance contract or identification number	356454G
Number of Individuals Covered	51
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,736
Total amount of fees paid to insurance company	USD $480
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,736
Insurance broker organization code?	3
Amount paid for insurance broker fees	463
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	GALLAGHER BENEFIT SVCS INC

WASHINGTON NATIONAL INSURANCE (National Association of Insurance Commissioners NAIC id number: 78174 )

Policy contract number

30334

Policy instance

Insurance contract or identification number	30334
Number of Individuals Covered	59
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,579
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $14,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,353
Insurance broker organization code?	3
Insurance broker name	CAPITAL AMERICAN LIFE INS CO.

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	334
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,845
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,845
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	7
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $380
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $380
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

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

Policy contract number

KM05996176

Policy instance

Insurance contract or identification number	KM05996176
Number of Individuals Covered	277
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $97
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $97
Insurance broker organization code?	3
Insurance broker name	JB SOLUTIONS LLC

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	354
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,062
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,062
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

WASHINGTON NATIONAL INSURANCE (National Association of Insurance Commissioners NAIC id number: 78174 )

Policy contract number

30334

Policy instance

Insurance contract or identification number	30334
Number of Individuals Covered	59
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,792
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $16,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7
Insurance broker organization code?	3
Insurance broker name	ROBERT J. PHILLIPS

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

Policy contract number

356454G

Policy instance

Insurance contract or identification number	356454G
Number of Individuals Covered	51
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,403
Total amount of fees paid to insurance company	USD $378
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	378
Additional information about fees paid to insurance broker	BONUS
Commission paid to Insurance Broker	USD $1,403
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

12109979

Policy instance

Insurance contract or identification number	12109979
Number of Individuals Covered	201
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,730
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,730
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON, INC

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

IIAS9960-7608-1

Policy instance

Insurance contract or identification number	IIAS9960-7608-1
Number of Individuals Covered	253
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,294
Total amount of fees paid to insurance company	USD $84,818
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $184,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3147
Additional information about fees paid to insurance broker	HIPAA ADMINISTRATION FEE
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $6,294
Insurance broker name	RESOURCEONE ADMINISTRATORS

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	8
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $392
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $392
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

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

Policy contract number

ADD-S06289

Policy instance

Insurance contract or identification number	ADD-S06289
Number of Individuals Covered	101
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,646
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $10,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,646
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

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

Policy contract number

GZ745

Policy instance

Insurance contract or identification number	GZ745
Number of Individuals Covered	285
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,241
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $25,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,241
Insurance broker name	WESLEY D. HERZBERG

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

IIAS9960-7608-1

Policy instance

Insurance contract or identification number	IIAS9960-7608-1
Number of Individuals Covered	264
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $6,416
Total amount of fees paid to insurance company	USD $81,577
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $172,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

356454G

Policy instance

Insurance contract or identification number	356454G
Number of Individuals Covered	53
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,557
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,319
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

GZ745

Policy instance

Insurance contract or identification number	GZ745
Number of Individuals Covered	297
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,292
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $25,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WASHINGTON NATIONAL INSURANCE (National Association of Insurance Commissioners NAIC id number: 78174 )

Policy contract number

30334

Policy instance

Insurance contract or identification number	30334
Number of Individuals Covered	67
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,878
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $17,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	363
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,137
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	9
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $422
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,224
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: 95478 )

Policy contract number

12109979

Policy instance

Insurance contract or identification number	12109979
Number of Individuals Covered	211
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,763
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ADD-S06289

Policy instance

Insurance contract or identification number	ADD-S06289
Number of Individuals Covered	104
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,638
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $10,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ADD-S06289

Policy instance

Insurance contract or identification number	ADD-S06289
Number of Individuals Covered	105
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,596
Other welfare benefits provided	ACCIDENTAL DEATH & DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $10,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,596
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

IIAS9960-7608-1

Policy instance

Insurance contract or identification number	IIAS9960-7608-1
Number of Individuals Covered	269
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,330
Total amount of fees paid to insurance company	USD $80,259
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $162,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3165
Additional information about fees paid to insurance broker	HIPAA ADMINISTRATION FEE
Insurance broker organization code?	5
Commission paid to Insurance Broker	USD $6,330
Insurance broker name	RESOURCEONE ADMINISTRATORS

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

12109979

Policy instance

Insurance contract or identification number	12109979
Number of Individuals Covered	210
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,821
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,821
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON, INC

FIRST CONTINENTAL LIFE AND ACCIDENT INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 64696 )

Policy contract number

FO6130

Policy instance

Insurance contract or identification number	FO6130
Number of Individuals Covered	388
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,831
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,831
Insurance broker organization code?	3
Insurance broker name	WANDA N. PHILLIPS

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

Policy contract number

356454G

Policy instance

Insurance contract or identification number	356454G
Number of Individuals Covered	53
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,603
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,603
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	10
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $432
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $432
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

WASHINGTON NATIONAL INSURANCE (National Association of Insurance Commissioners NAIC id number: 78174 )

Policy contract number

30334

Policy instance

Insurance contract or identification number	30334
Number of Individuals Covered	87
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,977
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $20,580
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
Insurance broker organization code?	3
Insurance broker name	ROBERT J. PHILLIPS

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

Policy contract number

G978

Policy instance

Insurance contract or identification number	G978
Number of Individuals Covered	358
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,042
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,042
Insurance broker organization code?	3
Insurance broker name	CHUCK THORNTON INC

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WAREHOUSE MARKET, INC. PROFIT SHARING PLAN [EIN = 830208489]

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Company Name:	WAREHOUSE MARKET, INC.
Employer identification number (EIN):	730501598
NAIC Classification:	445110
NAIC Description:	Supermarkets and Other Grocery (except Convenience) Stores

Jurisdiction of Incorporation:	Wyoming Corporations Division
Incorporation Date:	1968-06-27
Company Identification Number:	000103248
Legal Registered Office Address:	1062 Brundage Ln Sheridan United States of America (USA) 82801