401k Plan data: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA plan

OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 401k Plan overview

Plan Name	OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA
Plan identification number	501

OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

OKLAHOMA STATE UNIVERSITY FOUNDATION has sponsored the creation of one or more 401k plans.

Company Name: OKLAHOMA STATE UNIVERSITY FOUNDATION

Employer identification number (EIN): 736097060

NAIC Classification: 611000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 DONNA C KOEPPE 2023-10-13
501 2021-01-01 DONNA C KOEPPE 2022-07-29
501 2020-01-01 DONNA C KOEPPE 2021-07-28
501 2019-01-01 DONNA C KOEPPE 2020-09-28
501 2018-01-01 DONNA C KOEPPE 2019-08-13
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-07-01
501 2013-07-01
501 2012-07-01 DONNA C KOEPPE

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	DONNA C KOEPPE	2023-10-13
501	2021-01-01	DONNA C KOEPPE	2022-07-29
501	2020-01-01	DONNA C KOEPPE	2021-07-28
501	2019-01-01	DONNA C KOEPPE	2020-09-28
501	2018-01-01	DONNA C KOEPPE	2019-08-13
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-07-01
501	2013-07-01
501	2012-07-01	DONNA C KOEPPE

Plan Statistics for OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA

401k plan membership statisitcs for OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA

Measure Date Value
2022: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2022 401k membership
Total participants, beginning-of-year 2022-01-01 146
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 149
Number of retired or separated participants receiving benefits 2022-01-01 2
Number of other retired or separated participants entitled to future benefits 2022-01-01 2
Total of all active and inactive participants 2022-01-01 153
2021: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2021 401k membership
Total participants, beginning-of-year 2021-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 146
Number of retired or separated participants receiving benefits 2021-01-01 6
Number of other retired or separated participants entitled to future benefits 2021-01-01 1
Total of all active and inactive participants 2021-01-01 153
2020: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2020 401k membership
Total participants, beginning-of-year 2020-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 150
Number of retired or separated participants receiving benefits 2020-01-01 1
Number of other retired or separated participants entitled to future benefits 2020-01-01 1
Total of all active and inactive participants 2020-01-01 152
2019: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2019 401k membership
Total participants, beginning-of-year 2019-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 155
Number of retired or separated participants receiving benefits 2019-01-01 2
Total of all active and inactive participants 2019-01-01 157
2018: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2018 401k membership
Total participants, beginning-of-year 2018-01-01 147
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 155
Number of retired or separated participants receiving benefits 2018-01-01 3
Total of all active and inactive participants 2018-01-01 158
2017: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2017 401k membership
Total participants, beginning-of-year 2017-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 147
Number of retired or separated participants receiving benefits 2017-01-01 3
Total of all active and inactive participants 2017-01-01 150
2016: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2016 401k membership
Total participants, beginning-of-year 2016-01-01 151
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 141
Number of retired or separated participants receiving benefits 2016-01-01 2
Total of all active and inactive participants 2016-01-01 143
2015: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2015 401k membership
Total participants, beginning-of-year 2015-01-01 143
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 151
Total of all active and inactive participants 2015-01-01 151
2014: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2014 401k membership
Total participants, beginning-of-year 2014-07-01 161
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 143
Total of all active and inactive participants 2014-07-01 143
2013: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2013 401k membership
Total participants, beginning-of-year 2013-07-01 141
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 161
Total of all active and inactive participants 2013-07-01 161
2012: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2012 401k membership
Total participants, beginning-of-year 2012-07-01 140
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 140
Number of retired or separated participants receiving benefits 2012-07-01 1
Total of all active and inactive participants 2012-07-01 141

Measure	Date	Value
2022: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2022 401k membership
Total participants, beginning-of-year	2022-01-01	146
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	149
Number of retired or separated participants receiving benefits	2022-01-01	2
Number of other retired or separated participants entitled to future benefits	2022-01-01	2
Total of all active and inactive participants	2022-01-01	153
2021: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2021 401k membership
Total participants, beginning-of-year	2021-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	146
Number of retired or separated participants receiving benefits	2021-01-01	6
Number of other retired or separated participants entitled to future benefits	2021-01-01	1
Total of all active and inactive participants	2021-01-01	153
2020: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2020 401k membership
Total participants, beginning-of-year	2020-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	150
Number of retired or separated participants receiving benefits	2020-01-01	1
Number of other retired or separated participants entitled to future benefits	2020-01-01	1
Total of all active and inactive participants	2020-01-01	152
2019: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2019 401k membership
Total participants, beginning-of-year	2019-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	155
Number of retired or separated participants receiving benefits	2019-01-01	2
Total of all active and inactive participants	2019-01-01	157
2018: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2018 401k membership
Total participants, beginning-of-year	2018-01-01	147
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	155
Number of retired or separated participants receiving benefits	2018-01-01	3
Total of all active and inactive participants	2018-01-01	158
2017: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2017 401k membership
Total participants, beginning-of-year	2017-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	147
Number of retired or separated participants receiving benefits	2017-01-01	3
Total of all active and inactive participants	2017-01-01	150
2016: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2016 401k membership
Total participants, beginning-of-year	2016-01-01	151
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	141
Number of retired or separated participants receiving benefits	2016-01-01	2
Total of all active and inactive participants	2016-01-01	143
2015: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2015 401k membership
Total participants, beginning-of-year	2015-01-01	143
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	151
Total of all active and inactive participants	2015-01-01	151
2014: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2014 401k membership
Total participants, beginning-of-year	2014-07-01	161
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	143
Total of all active and inactive participants	2014-07-01	143
2013: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2013 401k membership
Total participants, beginning-of-year	2013-07-01	141
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	161
Total of all active and inactive participants	2013-07-01	161
2012: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2012 401k membership
Total participants, beginning-of-year	2012-07-01	140
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	140
Number of retired or separated participants receiving benefits	2012-07-01	1
Total of all active and inactive participants	2012-07-01	141

Form 5500 Responses for OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA

2022: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 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: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 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: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 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: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 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: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 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: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 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: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 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: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 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: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2012: OKLAHOMA STATE UNIVERSITY FOUNDATION CAFETERIA PLA 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	First time form 5500 has been submitted	Yes
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BP9F

Policy instance

Insurance contract or identification number	GVTL0BP9F
Number of Individuals Covered	55
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,641
Total amount of fees paid to insurance company	USD $396
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $16,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,641
Insurance broker organization code?	3
Amount paid for insurance broker fees	396
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	121
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,315
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,315
Insurance broker organization code?	3

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

Policy contract number

5956005

Policy instance

Insurance contract or identification number	5956005
Number of Individuals Covered	478
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $11,639
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $151,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,639
Insurance broker organization code?	3

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

Policy contract number

E3871126

Policy instance

Insurance contract or identification number	E3871126
Number of Individuals Covered	19
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,156
Total amount of fees paid to insurance company	USD $97
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $668
Insurance broker organization code?	3
Amount paid for insurance broker fees	64

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

Policy contract number

218799

Policy instance

Insurance contract or identification number	218799
Number of Individuals Covered	315
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $63,036
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,800,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,036
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BP9F

Policy instance

Insurance contract or identification number	GLTD0BP9F
Number of Individuals Covered	149
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,250
Total amount of fees paid to insurance company	USD $1,193
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,250
Insurance broker organization code?	3
Amount paid for insurance broker fees	1193
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BP9F

Policy instance

Insurance contract or identification number	GLUG0BP9F
Number of Individuals Covered	149
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,816
Total amount of fees paid to insurance company	USD $901
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $38,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,816
Insurance broker organization code?	3
Amount paid for insurance broker fees	901
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0BP9F

Policy instance

Insurance contract or identification number	GUG 0BP9F
Number of Individuals Covered	149
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,880
Total amount of fees paid to insurance company	USD $1,121
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,880
Insurance broker organization code?	3
Amount paid for insurance broker fees	1121
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	110
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,232
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,232
Insurance broker organization code?	3

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

Policy contract number

5956005

Policy instance

Insurance contract or identification number	5956005
Number of Individuals Covered	468
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,402
Total amount of fees paid to insurance company	USD $225
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $143,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,395
Insurance broker organization code?	3
Amount paid for insurance broker fees	225
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

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

Policy contract number

E3871126

Policy instance

Insurance contract or identification number	E3871126
Number of Individuals Covered	16
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,220
Total amount of fees paid to insurance company	USD $34
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $407
Amount paid for insurance broker fees	6
Insurance broker organization code?	3

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

Policy contract number

218799

Policy instance

Insurance contract or identification number	218799
Number of Individuals Covered	326
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $63,757
Total amount of fees paid to insurance company	USD $1,112
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,824,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,757
Amount paid for insurance broker fees	1112
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BP9F

Policy instance

Insurance contract or identification number	GLTD0BP9F
Number of Individuals Covered	143
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,963
Total amount of fees paid to insurance company	USD $1,246
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,963
Insurance broker organization code?	3
Amount paid for insurance broker fees	1246
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BP9F

Policy instance

Insurance contract or identification number	GLUG0BP9F
Number of Individuals Covered	143
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,004
Total amount of fees paid to insurance company	USD $933
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $30,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,004
Insurance broker organization code?	3
Amount paid for insurance broker fees	933
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0BP9F

Policy instance

Insurance contract or identification number	GUG 0BP9F
Number of Individuals Covered	143
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,605
Total amount of fees paid to insurance company	USD $1,171
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,605
Insurance broker organization code?	3
Amount paid for insurance broker fees	1171
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BP9F

Policy instance

Insurance contract or identification number	GVTL0BP9F
Number of Individuals Covered	52
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,322
Total amount of fees paid to insurance company	USD $389
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,322
Insurance broker organization code?	3
Amount paid for insurance broker fees	389
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	114
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,243
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,122
Insurance broker organization code?	3

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

Policy contract number

5956005

Policy instance

Insurance contract or identification number	5956005
Number of Individuals Covered	470
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,114
Total amount of fees paid to insurance company	USD $1,758
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $138,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,114
Amount paid for insurance broker fees	21
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

E3871126

Policy instance

Insurance contract or identification number	E3871126
Number of Individuals Covered	16
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,770
Total amount of fees paid to insurance company	USD $102
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $782
Amount paid for insurance broker fees	63
Insurance broker organization code?	3

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

Policy contract number

218799

Policy instance

Insurance contract or identification number	218799
Number of Individuals Covered	320
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $58,987
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,716,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,142
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BP9F

Policy instance

Insurance contract or identification number	GLTD0BP9F
Number of Individuals Covered	151
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $6,234
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,716
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BP9F

Policy instance

Insurance contract or identification number	GLUG0BP9F
Number of Individuals Covered	151
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,132
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 $31,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,872
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0BP9F

Policy instance

Insurance contract or identification number	GUG 0BP9F
Number of Individuals Covered	151
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,859
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,372
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BP9F

Policy instance

Insurance contract or identification number	GVTL0BP9F
Number of Individuals Covered	50
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,282
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 $12,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,174
Insurance broker organization code?	3

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
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 $1,598
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,598
Insurance broker organization code?	3

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

Policy contract number

5956005

Policy instance

Insurance contract or identification number	5956005
Number of Individuals Covered	158
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $10,901
Total amount of fees paid to insurance company	USD $1,757
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $148,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,901
Amount paid for insurance broker fees	54
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

466667

Policy instance

Insurance contract or identification number	466667
Number of Individuals Covered	162
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,447
Total amount of fees paid to insurance company	USD $525
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 $106,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,447
Amount paid for insurance broker fees	525
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

466668

Policy instance

Insurance contract or identification number	466668
Number of Individuals Covered	51
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,352
Total amount of fees paid to insurance company	USD $68
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,352
Amount paid for insurance broker fees	68
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

E3871126

Policy instance

Insurance contract or identification number	E3871126
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 $1,596
Total amount of fees paid to insurance company	USD $102
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $687
Amount paid for insurance broker fees	45
Insurance broker organization code?	3

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

Policy contract number

218799

Policy instance

Insurance contract or identification number	218799
Number of Individuals Covered	321
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $61,086
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,745,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,086
Insurance broker organization code?	3

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

Policy contract number

218799

Policy instance

Insurance contract or identification number	218799
Number of Individuals Covered	323
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $59,532
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,739,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,532
Insurance broker organization code?	3

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

Policy contract number

E3871126

Policy instance

Insurance contract or identification number	E3871126
Number of Individuals Covered	19
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,003
Total amount of fees paid to insurance company	USD $196
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $875
Amount paid for insurance broker fees	82
Insurance broker organization code?	3

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

Policy contract number

466668

Policy instance

Insurance contract or identification number	466668
Number of Individuals Covered	47
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,042
Total amount of fees paid to insurance company	USD $102
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,042
Amount paid for insurance broker fees	102
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

466667

Policy instance

Insurance contract or identification number	466667
Number of Individuals Covered	155
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,511
Total amount of fees paid to insurance company	USD $751
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 $100,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,511
Amount paid for insurance broker fees	751
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

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

Policy contract number

9579

Policy instance

Insurance contract or identification number	9579
Number of Individuals Covered	142
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $12,312
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
Commission paid to Insurance Broker	USD $12,312
Insurance broker organization code?	3

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	124
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,248
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,248
Insurance broker organization code?	3

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	118
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,222
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,222
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

466667

Policy instance

Insurance contract or identification number	466667
Number of Individuals Covered	147
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,273
Total amount of fees paid to insurance company	USD $668
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 $89,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,273
Amount paid for insurance broker fees	668
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

9579

Policy instance

Insurance contract or identification number	9579
Number of Individuals Covered	135
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,889
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
Commission paid to Insurance Broker	USD $10,889
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL CFR

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

Policy contract number

466668

Policy instance

Insurance contract or identification number	466668
Number of Individuals Covered	48
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,935
Total amount of fees paid to insurance company	USD $97
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,935
Amount paid for insurance broker fees	97
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

E3871126

Policy instance

Insurance contract or identification number	E3871126
Number of Individuals Covered	19
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,284
Total amount of fees paid to insurance company	USD $512
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,024
Amount paid for insurance broker fees	293
Insurance broker organization code?	3
Insurance broker name	KELLY W PUGH

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

Policy contract number

0904132

Policy instance

Insurance contract or identification number	0904132
Number of Individuals Covered	320
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 $55,068
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,573,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	55068
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	105
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,130
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,130
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

9579

Policy instance

Insurance contract or identification number	9579
Number of Individuals Covered	135
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,041
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
Commission paid to Insurance Broker	USD $9,041
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL CFR,

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

Policy contract number

466667

Policy instance

Insurance contract or identification number	466667
Number of Individuals Covered	146
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,016
Total amount of fees paid to insurance company	USD $610
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 $81,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,016
Amount paid for insurance broker fees	610
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

466668

Policy instance

Insurance contract or identification number	466668
Number of Individuals Covered	47
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,590
Total amount of fees paid to insurance company	USD $80
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,590
Amount paid for insurance broker fees	80
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

E3871126

Policy instance

Insurance contract or identification number	E3871126
Number of Individuals Covered	16
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,708
Total amount of fees paid to insurance company	USD $461
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,327
Amount paid for insurance broker fees	232
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	KELLY W PUGH

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

Policy contract number

0904132

Policy instance

Insurance contract or identification number	0904132
Number of Individuals Covered	131
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 $47,122
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,393,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	47122
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

E3871126

Policy instance

Insurance contract or identification number	E3871126
Number of Individuals Covered	11
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $401
Total amount of fees paid to insurance company	USD $45
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $185
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	MARILYN K EMBERSON

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	100
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,064
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,064
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

9579

Policy instance

Insurance contract or identification number	9579
Number of Individuals Covered	135
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $8,034
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 $8,034
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL CFR,

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

Policy contract number

001195

Policy instance

Insurance contract or identification number	001195
Number of Individuals Covered	281
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $56,877
Total amount of fees paid to insurance company	USD $1,270
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 $1,181,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,877
Amount paid for insurance broker fees	1270
Additional information about fees paid to insurance broker	AGENT TOTAL VOLUME BONUSES
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

466667

Policy instance

Insurance contract or identification number	466667
Number of Individuals Covered	143
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,358
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
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,358
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

466668

Policy instance

Insurance contract or identification number	466668
Number of Individuals Covered	40
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,712
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 $9,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,712
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL MIDWEST LTD

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	99
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $978
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $711
Insurance broker organization code?	3
Insurance broker name	CFR, INC.

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

Policy contract number

9579

Policy instance

Insurance contract or identification number	9579
Number of Individuals Covered	130
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,794
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 $7,794
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL CFR-J CONDRY

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

Policy contract number

150899

Policy instance

Insurance contract or identification number	150899
Number of Individuals Covered	161
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,151
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,829
Insurance broker organization code?	3
Insurance broker name	CFR, INC.

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

Policy contract number

150899

Policy instance

Insurance contract or identification number	150899
Number of Individuals Covered	134
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,208
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,692
Insurance broker organization code?	3
Insurance broker name	CFR, INC.

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

Policy contract number

001195

Policy instance

Insurance contract or identification number	001195
Number of Individuals Covered	267
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $58,680
Total amount of fees paid to insurance company	USD $2,840
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 $1,173,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,637
Insurance broker organization code?	3
Amount paid for insurance broker fees	2840
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS OR BONUSES
Insurance broker name	HUB INTERNATIONAL

COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 )

Policy contract number

CO1219

Policy instance

Insurance contract or identification number	CO1219
Number of Individuals Covered	247
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $58,000
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 $1,096,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,000
Insurance broker organization code?	3
Insurance broker name	CFR, INC.

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

Policy contract number

150899

Policy instance

Insurance contract or identification number	150899
Number of Individuals Covered	118
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,925
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,925
Insurance broker organization code?	3
Insurance broker name	CFR, INC.

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

Policy contract number

150899

Policy instance

Insurance contract or identification number	150899
Number of Individuals Covered	140
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,005
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,005
Insurance broker organization code?	3
Insurance broker name	CFR, INC.

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

Policy contract number

9579

Policy instance

Insurance contract or identification number	9579
Number of Individuals Covered	123
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,315
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 $6,315
Insurance broker organization code?	3
Insurance broker name	CFR, INC.

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

Policy contract number

30002469

Policy instance

Insurance contract or identification number	30002469
Number of Individuals Covered	78
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $960
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $960
Insurance broker organization code?	3
Insurance broker name	CFR, INC.

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Company Name:	OKLAHOMA STATE UNIVERSITY FOUNDATION
Employer identification number (EIN):	736097060
NAIC Classification:	611000