| Insurance contract or identification number | 30045270 |
| Number of Individuals Covered | 108 |
| Insurance policy start date | 2017-01-01 |
| Insurance policy end date | 2017-12-31 |
| Total amount of commissions paid to insurance broker | USD $1,454 |
| Total amount of fees paid to insurance company | USD $0 |
| Are there contracts with allocated funds for individual policies? | 0 |
| Are there contracts with allocated funds for group deferred annuity? | No |
| Are there contracts with allocated funds for types other than group deferred annuity or individual? | No |
| Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No |
| Contracts With Unallocated Funds Deposit Administration | 0 |
| Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No |
| Are there contracts with unallocated funds for contracts of type guaranteed investment? | No |
| Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No |
| Health Insurance Welfare Benefit | No |
| Dental Insurance Welfare Benefit | No |
| Vision Insurance Welfare Benefit | Yes |
| Life Insurance Welfare Benefit | No |
| Temporary Disability Insurance Welfare Benefit | No |
| Long Term Disability Insurance Welfare Benefit | No |
| Unemployment Insurance Welfare Benefit | No |
| Were dividends or retroactive rate refunds paid in cash? | No |
| Were dividends or retroactive rate refunds paid as a credit? | No |
| Welfare Benefit Premiums Paid to Carrier | USD $14,540 |
| Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
| Commission paid to Insurance Broker | USD $1,454 |
| Insurance broker organization code? | 3 |
| Insurance broker name | JOHN L. WORTHAM & SON, L.P. |
