401k Plan data: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN plan

FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 401k Plan overview

Plan Name	FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN
Plan identification number	503

FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY 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 Other welfare benefit cover

401k Sponsoring company profile

FALLS COMMUNITY HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: FALLS COMMUNITY HOSPITAL

Employer identification number (EIN): 741471231

NAIC Classification: 622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-01-01 JESSICA FORD 2023-10-02 JESSICA FORD 2023-10-02
503 2021-01-01 JESSICA FORD 2022-10-17 JESSICA FORD 2022-10-17
503 2020-01-01 JESSICA FORD 2021-10-11
503 2019-01-01 JESSICA FORD 2020-10-13
503 2018-01-01 JEFFREY LYLE 2019-10-11
503 2017-01-01
503 2017-01-01
503 2016-01-01
503 2015-01-01 WILLIS REESE
503 2014-01-01 WILLIS REESE
503 2014-01-01 WILLIS REESE
503 2013-01-01 WILLIS REESE
503 2012-01-01 WILLIS REESE
503 2011-01-01 WILLIS REESE
503 2010-01-01 PEGGY POLSTER BENEFITS COORDINATOR
503 2009-01-01 PEGGY POLSTER BENEFITS COORDINATOR

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2022-01-01	JESSICA FORD	2023-10-02	JESSICA FORD	2023-10-02
503	2021-01-01	JESSICA FORD	2022-10-17	JESSICA FORD	2022-10-17
503	2020-01-01	JESSICA FORD	2021-10-11
503	2019-01-01	JESSICA FORD	2020-10-13
503	2018-01-01	JEFFREY LYLE	2019-10-11
503	2017-01-01
503	2017-01-01
503	2016-01-01
503	2015-01-01	WILLIS REESE
503	2014-01-01	WILLIS REESE
503	2014-01-01	WILLIS REESE
503	2013-01-01	WILLIS REESE
503	2012-01-01	WILLIS REESE
503	2011-01-01	WILLIS REESE
503	2010-01-01	PEGGY POLSTER BENEFITS COORDINATOR
503	2009-01-01	PEGGY POLSTER BENEFITS COORDINATOR

Plan Statistics for FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN

401k plan membership statisitcs for FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN

Measure Date Value
2022: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 61
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 79
Total of all active and inactive participants 2022-01-01 79
Total participants 2022-01-01 79
2021: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 85
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 61
Total of all active and inactive participants 2021-01-01 61
Total participants 2021-01-01 61
2020: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 94
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 85
Total of all active and inactive participants 2020-01-01 85
Total participants 2020-01-01 85
2019: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 185
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 94
Total of all active and inactive participants 2019-01-01 94
Total participants 2019-01-01 94
2018: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 182
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 185
Total of all active and inactive participants 2018-01-01 185
Total participants 2018-01-01 185
2017: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 182
Total of all active and inactive participants 2017-01-01 182
Total participants 2017-01-01 182
2016: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 123
Total of all active and inactive participants 2016-01-01 123
Total participants 2016-01-01 123
2015: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 134
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 131
Total of all active and inactive participants 2015-01-01 131
Total participants 2015-01-01 131
2014: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 137
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 134
Total of all active and inactive participants 2014-01-01 134
Total participants 2014-01-01 134
2013: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 97
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 137
Total of all active and inactive participants 2013-01-01 137
Total participants 2013-01-01 137
2012: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 97
Total of all active and inactive participants 2012-01-01 97
Total participants 2012-01-01 97
2011: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 108
Total of all active and inactive participants 2011-01-01 108
Total participants 2011-01-01 108
2010: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 108
Total of all active and inactive participants 2010-01-01 108
Total participants 2010-01-01 108
2009: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 126
Total of all active and inactive participants 2009-01-01 126
Total participants 2009-01-01 126

Measure	Date	Value
2022: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	61
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	79
Total of all active and inactive participants	2022-01-01	79
Total participants	2022-01-01	79
2021: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	85
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	61
Total of all active and inactive participants	2021-01-01	61
Total participants	2021-01-01	61
2020: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	94
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	85
Total of all active and inactive participants	2020-01-01	85
Total participants	2020-01-01	85
2019: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	185
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	94
Total of all active and inactive participants	2019-01-01	94
Total participants	2019-01-01	94
2018: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	182
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	185
Total of all active and inactive participants	2018-01-01	185
Total participants	2018-01-01	185
2017: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	182
Total of all active and inactive participants	2017-01-01	182
Total participants	2017-01-01	182
2016: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	123
Total of all active and inactive participants	2016-01-01	123
Total participants	2016-01-01	123
2015: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	134
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	131
Total of all active and inactive participants	2015-01-01	131
Total participants	2015-01-01	131
2014: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	137
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	134
Total of all active and inactive participants	2014-01-01	134
Total participants	2014-01-01	134
2013: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	97
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	137
Total of all active and inactive participants	2013-01-01	137
Total participants	2013-01-01	137
2012: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	97
Total of all active and inactive participants	2012-01-01	97
Total participants	2012-01-01	97
2011: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	108
Total of all active and inactive participants	2011-01-01	108
Total participants	2011-01-01	108
2010: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	108
Total of all active and inactive participants	2010-01-01	108
Total participants	2010-01-01	108
2009: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	126
Total of all active and inactive participants	2009-01-01	126
Total participants	2009-01-01	126

Form 5500 Responses for FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN

2022: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY 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 funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY 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 funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY 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 funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: FALLS COMMUNITY HOSP & CLINIC SEC 125 PREMIUM ONLY PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GVTL0C2JM

Policy instance

Insurance contract or identification number	GVTL0C2JM
Number of Individuals Covered	42
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $4,228
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	LIFE & AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $20,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,228
Insurance broker organization code?	3

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

Policy contract number

GUPR0C2JM

Policy instance

Insurance contract or identification number	GUPR0C2JM
Number of Individuals Covered	26
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

GUDB0C2JM

Policy instance

Insurance contract or identification number	GUDB0C2JM
Number of Individuals Covered	45
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,855
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,855
Insurance broker organization code?	3

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

Policy contract number

GUC0C2JM

Policy instance

Insurance contract or identification number	GUC0C2JM
Number of Individuals Covered	29
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $2,626
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,626
Insurance broker organization code?	3

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

Policy contract number

GLUG0C2JM

Policy instance

Insurance contract or identification number	GLUG0C2JM
Number of Individuals Covered	79
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $176
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $176
Insurance broker organization code?	3

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

Policy contract number

GLLV0C2JM

Policy instance

Insurance contract or identification number	GLLV0C2JM
Number of Individuals Covered	36
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $703
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $703
Insurance broker organization code?	3

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

Policy contract number

226405

Policy instance

Insurance contract or identification number	226405
Number of Individuals Covered	61
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $22,694
Total amount of fees paid to insurance company	USD $558
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $481,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,043
Amount paid for insurance broker fees	558
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

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

Policy contract number

00546725

Policy instance

Insurance contract or identification number	00546725
Number of Individuals Covered	54
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,239
Total amount of fees paid to insurance company	USD $3,450
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $39,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,025
Insurance broker organization code?	3
Amount paid for insurance broker fees	3385
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

VDT602143

Policy instance

Insurance contract or identification number	VDT602143
Number of Individuals Covered	26
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $1,865
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,865
Insurance broker organization code?	3

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

Policy contract number

00546725

Policy instance

Insurance contract or identification number	00546725
Number of Individuals Covered	61
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,957
Total amount of fees paid to insurance company	USD $2,195
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $44,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,389
Insurance broker organization code?	3
Amount paid for insurance broker fees	2195
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

226405

Policy instance

Insurance contract or identification number	226405
Number of Individuals Covered	85
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $24,198
Total amount of fees paid to insurance company	USD $630
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $441,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,198
Amount paid for insurance broker fees	630
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

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

Policy contract number

VDT602144

Policy instance

Insurance contract or identification number	VDT602144
Number of Individuals Covered	15
Insurance policy start date	2020-01-01
Insurance policy end date	2021-01-01
Total amount of commissions paid to insurance broker	USD $540
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $540
Insurance broker organization code?	3

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

Policy contract number

VDT602144

Policy instance

Insurance contract or identification number	VDT602144
Number of Individuals Covered	14
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $521
Total amount of fees paid to insurance company	USD $19
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $521
Insurance broker organization code?	3
Amount paid for insurance broker fees	19
Additional information about fees paid to insurance broker	OVERRIDE

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

Policy contract number

00546725

Policy instance

Insurance contract or identification number	00546725
Number of Individuals Covered	94
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $21,464
Total amount of fees paid to insurance company	USD $1,270
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $79,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,161
Insurance broker organization code?	3
Amount paid for insurance broker fees	1270
Additional information about fees paid to insurance broker	FEES

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

Policy contract number

226405

Policy instance

Insurance contract or identification number	226405
Number of Individuals Covered	87
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $21,631
Total amount of fees paid to insurance company	USD $3,642
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $447,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,631
Amount paid for insurance broker fees	3642
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

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

Policy contract number

VDT602143

Policy instance

Insurance contract or identification number	VDT602143
Number of Individuals Covered	24
Insurance policy start date	2019-01-01
Insurance policy end date	2020-01-01
Total amount of commissions paid to insurance broker	USD $1,662
Total amount of fees paid to insurance company	USD $58
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,662
Insurance broker organization code?	3
Amount paid for insurance broker fees	58
Additional information about fees paid to insurance broker	OVERRIDE

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

0000024115

Policy instance

Insurance contract or identification number	0000024115
Number of Individuals Covered	48
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,364
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $9,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,182
Insurance broker organization code?	3

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

Policy contract number

226405

Policy instance

Insurance contract or identification number	226405
Number of Individuals Covered	99
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $27,068
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $554,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,846
Insurance broker organization code?	3

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

Policy contract number

00546725

Policy instance

Insurance contract or identification number	00546725
Number of Individuals Covered	71
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,630
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,063
Insurance broker organization code?	3

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

Policy contract number

SGM608686

Policy instance

Insurance contract or identification number	SGM608686
Number of Individuals Covered	185
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,633
Total amount of fees paid to insurance company	USD $1,032
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	SUPP. LIFE, DEPENDENT LIFE
Welfare Benefit Premiums Paid to Carrier	USD $16,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $607
Insurance broker organization code?	3
Amount paid for insurance broker fees	1032
Additional information about fees paid to insurance broker	OVERRIDE

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

Policy contract number

SOK606394

Policy instance

Insurance contract or identification number	SOK606394
Number of Individuals Covered	185
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $160
Total amount of fees paid to insurance company	USD $100
Other welfare benefits provided	ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to Carrier	USD $1,596
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	100
Additional information about fees paid to insurance broker	OVERRIDE

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

Policy contract number

VDT602143

Policy instance

Insurance contract or identification number	VDT602143
Number of Individuals Covered	23
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $1,193
Total amount of fees paid to insurance company	USD $825
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $430
Insurance broker organization code?	3
Amount paid for insurance broker fees	825
Additional information about fees paid to insurance broker	OVERRIDE

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

Policy contract number

VDT602144

Policy instance

Insurance contract or identification number	VDT602144
Number of Individuals Covered	15
Insurance policy start date	2018-01-01
Insurance policy end date	2019-01-01
Total amount of commissions paid to insurance broker	USD $383
Total amount of fees paid to insurance company	USD $263
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $245
Amount paid for insurance broker fees	263
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

Policy instance

Number of Individuals Covered	0
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $141
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEART/STROKE
Welfare Benefit Premiums Paid to Carrier	USD $877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $88
Insurance broker organization code?	3
Insurance broker name	ASPEN REINSURANCE GROUP, INC

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

Policy contract number

MG-100 OP119614

Policy instance

Insurance contract or identification number	MG-100 OP119614
Number of Individuals Covered	22
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,201
Other welfare benefits provided	MAJOR MEDICAL SUPPLEMENT
Welfare Benefit Premiums Paid to Carrier	USD $30,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,201
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

Policy instance

Number of Individuals Covered	54
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,829
Other welfare benefits provided	GROUP CANCER & SPECIFIED DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $22,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,484
Insurance broker organization code?	3
Insurance broker name	BAFFIN BAY MARKETING GROUP, LLC

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919000

Policy instance

Insurance contract or identification number	9041465919000
Number of Individuals Covered	85
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $-4
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-4
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

01-016902-00

Policy instance

Insurance contract or identification number	01-016902-00
Number of Individuals Covered	124
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,515
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 $26,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,047
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919001

Policy instance

Insurance contract or identification number	9041465919001
Number of Individuals Covered	43
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,598
Other welfare benefits provided	VOLUNTARY STD
Welfare Benefit Premiums Paid to Carrier	USD $24,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,504
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

Policy instance

Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $168
Other welfare benefits provided	INDIVIDUAL CANCER/SPECIFIED DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $115
Insurance broker organization code?	3
Insurance broker name	ASPEN REINSURANCE GROUP, INC

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

Policy contract number

908346

Policy instance

Insurance contract or identification number	908346
Number of Individuals Covered	182
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,908
Total amount of fees paid to insurance company	USD $28,230
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $639,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,908
Amount paid for insurance broker fees	28230
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT & BONUS
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SERVICES INC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

Policy instance

Number of Individuals Covered	4
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $135
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEART/STROKE
Welfare Benefit Premiums Paid to Carrier	USD $1,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $135
Insurance broker organization code?	3
Insurance broker name	H. CHARLES BROOKS

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919001

Policy instance

Insurance contract or identification number	9041465919001
Number of Individuals Covered	38
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,873
Other welfare benefits provided	VOLUNTARY STD
Welfare Benefit Premiums Paid to Carrier	USD $26,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,873
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

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

Policy contract number

G000AVFM

Policy instance

Insurance contract or identification number	G000AVFM
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 $4,338
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,338
Insurance broker organization code?	3
Insurance broker name	HOWARD CHARLES BROOKS

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919000

Policy instance

Insurance contract or identification number	9041465919000
Number of Individuals Covered	85
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,340
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,340
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

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

Policy contract number

MG-100 OP119614

Policy instance

Insurance contract or identification number	MG-100 OP119614
Number of Individuals Covered	35
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,152
Other welfare benefits provided	MAJOR MEDICAL SUPPLEMENT
Welfare Benefit Premiums Paid to Carrier	USD $36,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,152
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 )

Policy contract number

333560

Policy instance

Insurance contract or identification number	333560
Number of Individuals Covered	91
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $562
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $562
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT SOLUTIONS INC

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

Policy instance

Number of Individuals Covered	46
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,370
Other welfare benefits provided	CANCER AND SPECIFIED DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $22,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,370
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT SOLUTION

S & W HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95099 )

Policy contract number

007787

Policy instance

Insurance contract or identification number	007787
Number of Individuals Covered	115
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $14,890
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $550,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,890
Insurance broker organization code?	3
Insurance broker name	SCOTT & WHITE HEALTH PLAN

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919001

Policy instance

Insurance contract or identification number	9041465919001
Number of Individuals Covered	42
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $6,038
Other welfare benefits provided	VOLUNTARY STD
Welfare Benefit Premiums Paid to Carrier	USD $26,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,038
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

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

Policy contract number

863001G

Policy instance

Insurance contract or identification number	863001G
Number of Individuals Covered	134
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,332
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $24,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,908
Insurance broker organization code?	3
Insurance broker name	GALLAGHER BENEFIT SVCS INC.

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919000

Policy instance

Insurance contract or identification number	9041465919000
Number of Individuals Covered	82
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,900
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,900
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

Policy instance

Number of Individuals Covered	47
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,105
Other welfare benefits provided	CANCER AND SPECIFIED DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $25,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,105
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT SOLUTION

S & W HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95099 )

Policy contract number

007787

Policy instance

Insurance contract or identification number	007787
Number of Individuals Covered	133
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10,129
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $404,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,129
Insurance broker organization code?	3
Insurance broker name	SCOTT & WHITE HEALTH PLAN

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

Policy contract number

MG-100 OP119614

Policy instance

Insurance contract or identification number	MG-100 OP119614
Number of Individuals Covered	30
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $7,240
Other welfare benefits provided	MAJOR MEDICAL SUPPLEMENT
Welfare Benefit Premiums Paid to Carrier	USD $42,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,240
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 )

Policy contract number

333560

Policy instance

Insurance contract or identification number	333560
Number of Individuals Covered	97
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $527
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $527
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT SOLUTIONS INC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

Policy instance

Number of Individuals Covered	4
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $191
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEART/STROKE
Welfare Benefit Premiums Paid to Carrier	USD $1,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $191
Insurance broker organization code?	3
Insurance broker name	H. CHARLES BROOKS

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

Policy contract number

863001G

Policy instance

Insurance contract or identification number	863001G
Number of Individuals Covered	137
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,992
Total amount of fees paid to insurance company	USD $399
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,395
Insurance broker organization code?	3
Amount paid for insurance broker fees	399
Additional information about fees paid to insurance broker	OTHER
Insurance broker name	INS POINT LLC

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-400089

Policy instance

Insurance contract or identification number	010-400089
Number of Individuals Covered	101
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $656
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $656
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

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

Policy contract number

MG-100 OP119614

Policy instance

Insurance contract or identification number	MG-100 OP119614
Number of Individuals Covered	34
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $7,231
Other welfare benefits provided	MAJOR MEDICAL SUPPLEMENT
Welfare Benefit Premiums Paid to Carrier	USD $42,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,231
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

Policy instance

Number of Individuals Covered	5
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $230
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEART/STROKE
Welfare Benefit Premiums Paid to Carrier	USD $2,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $230
Insurance broker organization code?	3
Insurance broker name	H. CHARLES BROOKS

SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 )

Policy contract number

P62W85

Policy instance

Insurance contract or identification number	P62W85
Number of Individuals Covered	19
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,921
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

62W200

Policy instance

Insurance contract or identification number	62W200
Number of Individuals Covered	112
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,349
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $306,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,027
Insurance broker organization code?	3
Insurance broker name	INSOURCE BENEFITS

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919000

Policy instance

Insurance contract or identification number	9041465919000
Number of Individuals Covered	86
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,978
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

863001G

Policy instance

Insurance contract or identification number	863001G
Number of Individuals Covered	137
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,992
Total amount of fees paid to insurance company	USD $399
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919001

Policy instance

Insurance contract or identification number	9041465919001
Number of Individuals Covered	42
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,937
Other welfare benefits provided	VOLUNTARY STD
Welfare Benefit Premiums Paid to Carrier	USD $30,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,937
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919001

Policy instance

Insurance contract or identification number	9041465919001
Number of Individuals Covered	42
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,937
Other welfare benefits provided	VOLUNTARY STD
Welfare Benefit Premiums Paid to Carrier	USD $30,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

9041465919000

Policy instance

Insurance contract or identification number	9041465919000
Number of Individuals Covered	86
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,978
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,978
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

Policy instance

Number of Individuals Covered	59
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,428
Other welfare benefits provided	CANCER AND SPECIFIED DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $27,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,259
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT SOLUTIONS

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

62W200

Policy instance

Insurance contract or identification number	62W200
Number of Individuals Covered	112
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,349
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $306,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,349
Insurance broker organization code?	3
Insurance broker name	INSOURCE BENEFITS

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-400089

Policy instance

Insurance contract or identification number	010-400089
Number of Individuals Covered	110
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $526
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $526
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

Policy instance

Number of Individuals Covered	5
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $212
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	HEART/STROKE
Welfare Benefit Premiums Paid to Carrier	USD $2,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $212
Insurance broker organization code?	3
Insurance broker name	H. CHARLES BROOKS

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

Policy instance

Number of Individuals Covered	63
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,502
Other welfare benefits provided	CANCER AND SPECIFIED DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $28,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,502
Insurance broker organization code?	3
Insurance broker name	CORPORATE BENEFIT SOLUTION

SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 )

Policy contract number

P62W85

Policy instance

Insurance contract or identification number	P62W85
Number of Individuals Covered	19
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,921
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $78,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,921
Insurance broker organization code?	3
Insurance broker name	INSOURCE BENEFITS

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

000AST000

Policy instance

Insurance contract or identification number	000AST000
Number of Individuals Covered	84
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $8,571
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY STD
Welfare Benefit Premiums Paid to Carrier	USD $56,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,838
Insurance broker organization code?	3
Insurance broker name	BENEFIT RESEARCH CORPORATION

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

Policy contract number

863001G

Policy instance

Insurance contract or identification number	863001G
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 $4,425
Total amount of fees paid to insurance company	USD $443
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,655
Insurance broker organization code?	3
Amount paid for insurance broker fees	443
Additional information about fees paid to insurance broker	OTHER
Insurance broker name	INS POINT LLC

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

Policy contract number

863001G

Policy instance

Insurance contract or identification number	863001G
Number of Individuals Covered	126
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,318
Total amount of fees paid to insurance company	USD $332
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $16,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-400089

Policy instance

Insurance contract or identification number	010-400089
Number of Individuals Covered	40
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $459
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SHA, L.L.C. (National Association of Insurance Commissioners NAIC id number: 95138 )

Policy contract number

62W200

Policy instance

Insurance contract or identification number	62W200
Number of Individuals Covered	116
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,469
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $279,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

Policy instance

Number of Individuals Covered	9
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $582
Health Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER AND SPECIFIED DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $5,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

Policy instance

Number of Individuals Covered	71
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,926
Other welfare benefits provided	CANCER AND SPECIFIED DISEASE
Welfare Benefit Premiums Paid to Carrier	USD $24,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 )

Policy contract number

P62W85

Policy instance

Insurance contract or identification number	P62W85
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $150
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

000AST000

Policy instance

Insurance contract or identification number	000AST000
Number of Individuals Covered	112
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $8,809
Dental Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY STD
Welfare Benefit Premiums Paid to Carrier	USD $57,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

720808900

Policy instance

Insurance contract or identification number	720808900
Number of Individuals Covered	21
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,436
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

C30551

Policy instance

Insurance contract or identification number	C30551
Number of Individuals Covered	22
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,978
Total amount of fees paid to insurance company	USD $1,682
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $16,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

Policy instance

Number of Individuals Covered	10
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,084
Total amount of fees paid to insurance company	USD $414
Other welfare benefits provided	CANCER
Welfare Benefit Premiums Paid to Carrier	USD $4,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

863001G

Policy instance

Insurance contract or identification number	863001G
Number of Individuals Covered	125
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,412
Total amount of fees paid to insurance company	USD $128
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $15,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 )

Policy contract number

62W200

Policy instance

Insurance contract or identification number	62W200
Number of Individuals Covered	101
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $13,080
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $335,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

010-400089

Policy instance

Insurance contract or identification number	010-400089
Number of Individuals Covered	37
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $3,982
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

SRP1383

Policy instance

Insurance contract or identification number	SRP1383
Number of Individuals Covered	5
Total amount of commissions paid to insurance broker	USD $339
Total amount of fees paid to insurance company	USD $212
Other welfare benefits provided	HEART ATTACK/STROKE
Welfare Benefit Premiums Paid to Carrier	USD $2,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	FALLS COMMUNITY HOSPITAL
Employer identification number (EIN):	741471231
NAIC Classification:	622000
NAIC Description:	Hospitals