401k Plan data: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN plan

CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	501

CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND 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)

401k Sponsoring company profile

CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL INC. has sponsored the creation of one or more 401k plans.

Company Name: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL INC.

Employer identification number (EIN): 730955756

NAIC Classification: 813000
NAIC Description: Religious, Grantmaking, Civic, Professional, and Similar Organizations

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 MONICA KRIENKE 2024-05-22
501 2022-01-01 MONICA KRIENKE 2023-09-14
501 2021-01-01 MONICA KRIENKE 2022-07-21
501 2020-01-01
501 2019-01-01
501 2018-01-01 MONICA KRIENKE
501 2017-01-01 MONICA TIPPIT
501 2016-01-01 MONICA TIPPIT
501 2015-01-01 MONICA TIPPIT
501 2014-01-01 MONICA TIPPIT
501 2013-01-01 MONICA TIPPIT
501 2012-01-01 MONICA TIPPIT
501 2011-01-01 MONICA TIPPIT

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-01-01	MONICA KRIENKE	2024-05-22
501	2022-01-01	MONICA KRIENKE	2023-09-14
501	2021-01-01	MONICA KRIENKE	2022-07-21
501	2020-01-01
501	2019-01-01
501	2018-01-01	MONICA KRIENKE
501	2017-01-01	MONICA TIPPIT
501	2016-01-01	MONICA TIPPIT
501	2015-01-01	MONICA TIPPIT
501	2014-01-01	MONICA TIPPIT
501	2013-01-01	MONICA TIPPIT
501	2012-01-01	MONICA TIPPIT
501	2011-01-01	MONICA TIPPIT

Plan Statistics for CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2023: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 338
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 340
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 340
Number of employers contributing to the scheme 2023-01-01 0
2022: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 321
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 338
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 338
Number of employers contributing to the scheme 2022-01-01 0
2021: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 241
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 275
Number of retired or separated participants receiving benefits 2021-01-01 3
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 278
Number of employers contributing to the scheme 2021-01-01 0
2020: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 216
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 235
Number of retired or separated participants receiving benefits 2020-01-01 2
Total of all active and inactive participants 2020-01-01 237
2019: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 196
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 215
Number of retired or separated participants receiving benefits 2019-01-01 1
Total of all active and inactive participants 2019-01-01 216
2018: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 163
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 194
Number of retired or separated participants receiving benefits 2018-01-01 2
Number of other retired or separated participants entitled to future benefits 2018-01-01 1
Total of all active and inactive participants 2018-01-01 197
2017: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 158
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 161
Number of retired or separated participants receiving benefits 2017-01-01 1
Number of other retired or separated participants entitled to future benefits 2017-01-01 1
Total of all active and inactive participants 2017-01-01 163
2016: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 148
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 156
Number of retired or separated participants receiving benefits 2016-01-01 1
Total of all active and inactive participants 2016-01-01 157
2015: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 139
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 144
Total of all active and inactive participants 2015-01-01 144
2014: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 134
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 136
Total of all active and inactive participants 2014-01-01 136
2013: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 127
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 128
Number of retired or separated participants receiving benefits 2013-01-01 2
Total of all active and inactive participants 2013-01-01 130
2012: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 123
Total of all active and inactive participants 2012-01-01 123
2011: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 128
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 128

Measure	Date	Value
2023: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	338
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	340
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	340
Number of employers contributing to the scheme	2023-01-01	0
2022: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	321
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	338
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	338
Number of employers contributing to the scheme	2022-01-01	0
2021: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	241
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	275
Number of retired or separated participants receiving benefits	2021-01-01	3
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	278
Number of employers contributing to the scheme	2021-01-01	0
2020: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	216
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	235
Number of retired or separated participants receiving benefits	2020-01-01	2
Total of all active and inactive participants	2020-01-01	237
2019: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	196
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	215
Number of retired or separated participants receiving benefits	2019-01-01	1
Total of all active and inactive participants	2019-01-01	216
2018: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	163
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	194
Number of retired or separated participants receiving benefits	2018-01-01	2
Number of other retired or separated participants entitled to future benefits	2018-01-01	1
Total of all active and inactive participants	2018-01-01	197
2017: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	158
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	161
Number of retired or separated participants receiving benefits	2017-01-01	1
Number of other retired or separated participants entitled to future benefits	2017-01-01	1
Total of all active and inactive participants	2017-01-01	163
2016: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	148
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	156
Number of retired or separated participants receiving benefits	2016-01-01	1
Total of all active and inactive participants	2016-01-01	157
2015: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	139
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	144
Total of all active and inactive participants	2015-01-01	144
2014: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	134
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	136
Total of all active and inactive participants	2014-01-01	136
2013: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	127
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	128
Number of retired or separated participants receiving benefits	2013-01-01	2
Total of all active and inactive participants	2013-01-01	130
2012: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	123
Total of all active and inactive participants	2012-01-01	123
2011: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	128
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	128

Form 5500 Responses for CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN

2023: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2018: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2017: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2016: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2015: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2014: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2013: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2012: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE 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 benefit arrangement – Insurance	Yes
2011: CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GL160411

Policy instance

Insurance contract or identification number	GL160411
Number of Individuals Covered	340
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $46,493
Total amount of fees paid to insurance company	USD $4,269
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $333,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0DH

Policy instance

Insurance contract or identification number	0DH
Number of Individuals Covered	594
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	978
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $209,089
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,228,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

GL160411

Policy instance

Insurance contract or identification number	GL160411
Number of Individuals Covered	307
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $39,613
Total amount of fees paid to insurance company	USD $3,356
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $284,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,613
Amount paid for insurance broker fees	3356
Additional information about fees paid to insurance broker	TOTAL ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

540739 0010

Policy instance

Insurance contract or identification number	540739 0010
Number of Individuals Covered	205
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,592
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $35,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,592
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	871
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $176,162
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,404,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $176,162
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	775
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $168,788
Total amount of fees paid to insurance company	USD $2,410
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,376,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $168,788
Amount paid for insurance broker fees	2410
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	276
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL160411

Policy instance

Insurance contract or identification number	GL160411
Number of Individuals Covered	240
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $31,218
Total amount of fees paid to insurance company	USD $5,115
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $223,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,218
Amount paid for insurance broker fees	5115
Additional information about fees paid to insurance broker	TOTAL ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

540739 0010

Policy instance

Insurance contract or identification number	540739 0010
Number of Individuals Covered	170
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,306
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $33,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,306
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	232
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 160411

Policy instance

Insurance contract or identification number	GL 160411
Number of Individuals Covered	212
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $14,764
Total amount of fees paid to insurance company	USD $1,883
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $98,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,764
Amount paid for insurance broker fees	1883
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

VPL 303111

Policy instance

Insurance contract or identification number	VPL 303111
Number of Individuals Covered	118
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $8,458
Total amount of fees paid to insurance company	USD $1,232
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,458
Amount paid for insurance broker fees	1232
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

VAR 208518

Policy instance

Insurance contract or identification number	VAR 208518
Number of Individuals Covered	135
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $510
Total amount of fees paid to insurance company	USD $67
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $510
Amount paid for insurance broker fees	67
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

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

Policy contract number

VPS 328164

Policy instance

Insurance contract or identification number	VPS 328164
Number of Individuals Covered	129
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,701
Total amount of fees paid to insurance company	USD $1,638
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,701
Amount paid for insurance broker fees	1638
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	660
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $158,036
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,221,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $158,036
Insurance broker organization code?	3

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

Policy contract number

540739

Policy instance

Insurance contract or identification number	540739
Number of Individuals Covered	135
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,802
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,802
Insurance broker organization code?	3

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	215
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GL 160411

Policy instance

Insurance contract or identification number	GL 160411
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 $7,061
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 $47,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,061
Insurance broker organization code?	3

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

Policy contract number

VPL 303111

Policy instance

Insurance contract or identification number	VPL 303111
Number of Individuals Covered	123
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,622
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,622
Insurance broker organization code?	3

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

Policy contract number

VAR 208518

Policy instance

Insurance contract or identification number	VAR 208518
Number of Individuals Covered	307
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $253
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $253
Insurance broker organization code?	3

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

Policy contract number

VPS 328164

Policy instance

Insurance contract or identification number	VPS 328164
Number of Individuals Covered	125
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,914
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,914
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	610
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $153,720
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,074,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $153,720
Insurance broker organization code?	3

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

Policy contract number

540739

Policy instance

Insurance contract or identification number	540739
Number of Individuals Covered	118
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,254
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,254
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM602250

Policy instance

Insurance contract or identification number	SGM602250
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $988
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $988
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600616

Policy instance

Insurance contract or identification number	VDT600616
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $693
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $693
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601375

Policy instance

Insurance contract or identification number	SOK601375
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $105
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,047
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

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600423

Policy instance

Insurance contract or identification number	VDT600423
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $910
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $910
Insurance broker organization code?	3

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	193
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM602250

Policy instance

Insurance contract or identification number	SGM602250
Number of Individuals Covered	192
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,466
Total amount of fees paid to insurance company	USD $818
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,466
Amount paid for insurance broker fees	818
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600616

Policy instance

Insurance contract or identification number	VDT600616
Number of Individuals Covered	110
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,790
Total amount of fees paid to insurance company	USD $608
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,790
Amount paid for insurance broker fees	608
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601375

Policy instance

Insurance contract or identification number	SOK601375
Number of Individuals Covered	192
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $566
Total amount of fees paid to insurance company	USD $77
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $566
Amount paid for insurance broker fees	77
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600423

Policy instance

Insurance contract or identification number	VDT600423
Number of Individuals Covered	113
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,026
Total amount of fees paid to insurance company	USD $829
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,026
Amount paid for insurance broker fees	829
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	549
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $102,389
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,618,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $102,389
Insurance broker organization code?	3

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

Policy contract number

540739

Policy instance

Insurance contract or identification number	540739
Number of Individuals Covered	101
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,869
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,869
Insurance broker organization code?	3

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

Policy contract number

540739

Policy instance

Insurance contract or identification number	540739
Number of Individuals Covered	91
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,755
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,755
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	437
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $91,543
Total amount of fees paid to insurance company	USD $1,560
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,288,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91,543
Amount paid for insurance broker fees	1560
Additional information about fees paid to insurance broker	SPECIAL PROGRAM FEES
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600423

Policy instance

Insurance contract or identification number	VDT600423
Number of Individuals Covered	116
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,405
Total amount of fees paid to insurance company	USD $1,446
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,405
Amount paid for insurance broker fees	1202
Additional information about fees paid to insurance broker	SALES & SERVICE AND OVERRIDE FEES
Insurance broker organization code?	3
Insurance broker name	C2 CENTRIC LLC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601375

Policy instance

Insurance contract or identification number	SOK601375
Number of Individuals Covered	161
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $543
Total amount of fees paid to insurance company	USD $163
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $543
Amount paid for insurance broker fees	138
Additional information about fees paid to insurance broker	SALES & SERVICE AND OVERRIDE FEES
Insurance broker organization code?	3
Insurance broker name	C2 CENTRIC LLC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600616

Policy instance

Insurance contract or identification number	VDT600616
Number of Individuals Covered	102
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,893
Total amount of fees paid to insurance company	USD $1,001
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $38,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,893
Amount paid for insurance broker fees	828
Additional information about fees paid to insurance broker	SALES & SERVICE AND OVERRIDE FEES
Insurance broker organization code?	3
Insurance broker name	C2 CENTRIC LLC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM602250

Policy instance

Insurance contract or identification number	SGM602250
Number of Individuals Covered	161
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,437
Total amount of fees paid to insurance company	USD $1,496
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,437
Amount paid for insurance broker fees	1249
Additional information about fees paid to insurance broker	SALES & SERIVCE AND OVERRIDE FEES
Insurance broker organization code?	3
Insurance broker name	C2 CENTRIC LLC

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	157
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600423

Policy instance

Insurance contract or identification number	VDT600423
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,420
Total amount of fees paid to insurance company	USD $658
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,420
Amount paid for insurance broker fees	658
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601375

Policy instance

Insurance contract or identification number	SOK601375
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $381
Total amount of fees paid to insurance company	USD $76
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $381
Amount paid for insurance broker fees	76
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600616

Policy instance

Insurance contract or identification number	VDT600616
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,289
Total amount of fees paid to insurance company	USD $449
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,289
Amount paid for insurance broker fees	449
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM602250

Policy instance

Insurance contract or identification number	SGM602250
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,434
Total amount of fees paid to insurance company	USD $647
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,434
Amount paid for insurance broker fees	647
Additional information about fees paid to insurance broker	OVERRIDE FEES
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	151
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	415
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $67,192
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,743,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67,192
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

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

Policy contract number

540739

Policy instance

Insurance contract or identification number	540739
Number of Individuals Covered	79
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,148
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,148
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	382
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $60,791
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 $1,577,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $60,791
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM602250

Policy instance

Insurance contract or identification number	SGM602250
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,469
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,469
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600616

Policy instance

Insurance contract or identification number	VDT600616
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,400
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,400
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601375

Policy instance

Insurance contract or identification number	SOK601375
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $408
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $408
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600423

Policy instance

Insurance contract or identification number	VDT600423
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,530
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,530
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	139
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $12,748
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12748
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600423

Policy instance

Insurance contract or identification number	VDT600423
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,727
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,727
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601375

Policy instance

Insurance contract or identification number	SOK601375
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $312
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $312
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600616

Policy instance

Insurance contract or identification number	VDT600616
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,893
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,893
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM602250

Policy instance

Insurance contract or identification number	SGM602250
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,945
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,945
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	128
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	129
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $47,914
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 $1,444,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,914
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	334
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $68,206
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 $1,364,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $68,206
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	124
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,081
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,081
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM602250

Policy instance

Insurance contract or identification number	SGM602250
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,629
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,629
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600616

Policy instance

Insurance contract or identification number	VDT600616
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,685
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,685
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601375

Policy instance

Insurance contract or identification number	SOK601375
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $327
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
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $327
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600423

Policy instance

Insurance contract or identification number	VDT600423
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,653
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
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,653
Insurance broker organization code?	3
Insurance broker name	HOLMES MURPHY & ASSOCIATES, INC.

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

VDT600423

Policy instance

Insurance contract or identification number	VDT600423
Number of Individuals Covered	120
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,638
Total amount of fees paid to insurance company	USD $739
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	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 $26,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM602250

Policy instance

Insurance contract or identification number	SGM602250
Number of Individuals Covered	120
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,233
Total amount of fees paid to insurance company	USD $599
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $22,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD602169

Policy instance

Insurance contract or identification number	SGD602169
Number of Individuals Covered	120
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,659
Total amount of fees paid to insurance company	USD $454
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

Y06050

Policy instance

Insurance contract or identification number	Y06050
Number of Individuals Covered	343
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $99,980
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,263,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601375

Policy instance

Insurance contract or identification number	SOK601375
Number of Individuals Covered	120
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $258
Total amount of fees paid to insurance company	USD $68
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,582
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

2902

Policy instance

Insurance contract or identification number	2902
Number of Individuals Covered	123
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,507
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL INC.
Employer identification number (EIN):	730955756
NAIC Classification:	813000
NAIC Description:	Religious, Grantmaking, Civic, Professional, and Similar Organizations