401k Plan data: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN plan

HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN
Plan identification number	501

HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

HILL COUNTRY MEMORIAL HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name: HILL COUNTRY MEMORIAL HOSPITAL

Employer identification number (EIN): 746083124

NAIC Classification: 622000
NAIC Description: Hospitals

Additional information about HILL COUNTRY MEMORIAL HOSPITAL

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 1966-12-07

Company Identification Number: 0022997201

Legal Registered Office Address: PO BOX 835

FREDERICKSBRG
United States of America (USA)
78624

More information about HILL COUNTRY MEMORIAL HOSPITAL

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 JAYNE POPE 2023-09-26 JAYNE POPE 2023-09-26
501 2021-01-01 SUSAN NEVES 2022-10-13 SUSAN NEVES 2022-10-13
501 2020-01-01 SUSAN NEVES 2021-10-07
501 2019-01-01 ALYSHA METZGER 2020-10-13
501 2018-01-01 ALYSHA METZGER 2019-10-14
501 2017-01-01
501 2016-01-01
501 2015-01-01 ALYSHA METZGER
501 2014-01-01 ALYSHA METZGER
501 2013-01-01 ALYSHA METZGER
501 2012-01-01 ALYSHA METZGER
501 2011-01-01 ALYSHA METZGER
501 2009-01-01 ERIN CATES SR DIR OF HUMAN RES
501 2009-01-01 ERIN CATES SR DIR OF HUMAN RES

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	JAYNE POPE	2023-09-26	JAYNE POPE	2023-09-26
501	2021-01-01	SUSAN NEVES	2022-10-13	SUSAN NEVES	2022-10-13
501	2020-01-01	SUSAN NEVES	2021-10-07
501	2019-01-01	ALYSHA METZGER	2020-10-13
501	2018-01-01	ALYSHA METZGER	2019-10-14
501	2017-01-01
501	2016-01-01
501	2015-01-01	ALYSHA METZGER
501	2014-01-01	ALYSHA METZGER
501	2013-01-01	ALYSHA METZGER
501	2012-01-01	ALYSHA METZGER
501	2011-01-01	ALYSHA METZGER
501	2009-01-01	ERIN CATES SR DIR OF HUMAN RES
501	2009-01-01	ERIN CATES SR DIR OF HUMAN RES

Plan Statistics for HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN

401k plan membership statisitcs for HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN

Measure Date Value
2022: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 678
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 632
Total of all active and inactive participants 2022-01-01 632
Total participants 2022-01-01 632
2021: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 706
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 678
Total of all active and inactive participants 2021-01-01 678
Total participants 2021-01-01 678
2020: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 696
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 706
Total of all active and inactive participants 2020-01-01 706
Total participants 2020-01-01 706
2019: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 629
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 696
Total of all active and inactive participants 2019-01-01 696
Total participants 2019-01-01 696
2018: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 626
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 629
Total of all active and inactive participants 2018-01-01 629
Total participants 2018-01-01 629
2017: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 586
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 626
Total of all active and inactive participants 2017-01-01 626
Total participants 2017-01-01 626
2016: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 550
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 586
Total of all active and inactive participants 2016-01-01 586
Total participants 2016-01-01 586
2015: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 549
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 550
Total of all active and inactive participants 2015-01-01 550
Total participants 2015-01-01 550
2014: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 509
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 549
Total of all active and inactive participants 2014-01-01 549
Total participants 2014-01-01 549
2013: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 366
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 509
Total of all active and inactive participants 2013-01-01 509
Total participants 2013-01-01 509
2012: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 394
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 366
Total of all active and inactive participants 2012-01-01 366
Total participants 2012-01-01 366
2011: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 416
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 394
Total of all active and inactive participants 2011-01-01 394
Total participants 2011-01-01 394
2009: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 415
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 443
Total of all active and inactive participants 2009-01-01 443
Total participants 2009-01-01 443

Measure	Date	Value
2022: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	678
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	632
Total of all active and inactive participants	2022-01-01	632
Total participants	2022-01-01	632
2021: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	706
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	678
Total of all active and inactive participants	2021-01-01	678
Total participants	2021-01-01	678
2020: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	696
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	706
Total of all active and inactive participants	2020-01-01	706
Total participants	2020-01-01	706
2019: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	629
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	696
Total of all active and inactive participants	2019-01-01	696
Total participants	2019-01-01	696
2018: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	626
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	629
Total of all active and inactive participants	2018-01-01	629
Total participants	2018-01-01	629
2017: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	586
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	626
Total of all active and inactive participants	2017-01-01	626
Total participants	2017-01-01	626
2016: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	550
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	586
Total of all active and inactive participants	2016-01-01	586
Total participants	2016-01-01	586
2015: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	549
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	550
Total of all active and inactive participants	2015-01-01	550
Total participants	2015-01-01	550
2014: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	509
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	549
Total of all active and inactive participants	2014-01-01	549
Total participants	2014-01-01	549
2013: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	366
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	509
Total of all active and inactive participants	2013-01-01	509
Total participants	2013-01-01	509
2012: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	394
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	366
Total of all active and inactive participants	2012-01-01	366
Total participants	2012-01-01	366
2011: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	416
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	394
Total of all active and inactive participants	2011-01-01	394
Total participants	2011-01-01	394
2009: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	415
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	443
Total of all active and inactive participants	2009-01-01	443
Total participants	2009-01-01	443

Form 5500 Responses for HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN

2022: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan 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: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: HILL COUNTRY MEMORIAL HOSPITAL WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

0219896

Policy instance

Insurance contract or identification number	0219896
Number of Individuals Covered	139
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,927
Total amount of fees paid to insurance company	USD $89
Other welfare benefits provided	CRITICAL ILLNESS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $29,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,279
Insurance broker organization code?	3
Amount paid for insurance broker fees	89
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION & SUPPLEMENTAL COMPENSATION

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	582
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $18,526
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,310
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	6
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,567
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 $1,495
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	170
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $31,510
Temporary 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 $16,538
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

CV785

Policy instance

Insurance contract or identification number	CV785
Number of Individuals Covered	51
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,695
Total amount of fees paid to insurance company	USD $350
Other welfare benefits provided	CANCER, INTENSIVE CARE, & RECOVERY
Welfare Benefit Premiums Paid to Carrier	USD $52,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39
Insurance broker organization code?	3
Amount paid for insurance broker fees	238
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	371
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Welfare Benefit Premiums Paid to Carrier	USD $807,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5955479

Policy instance

Insurance contract or identification number	5955479
Number of Individuals Covered	632
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $39,715
Total amount of fees paid to insurance company	USD $801
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $301,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,986
Insurance broker organization code?	3
Amount paid for insurance broker fees	801
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION & SUPPLEMENTAL COMPENSATION

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	566
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $21,577
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 $15,768
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	5
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,678
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 $2,005
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	187
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $31,402
Temporary 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 $22,837
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

CV785

Policy instance

Insurance contract or identification number	CV785
Number of Individuals Covered	65
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,719
Other welfare benefits provided	CANCER, INTENSIVE CARE, & RECOVERY
Welfare Benefit Premiums Paid to Carrier	USD $46,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $612
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	380
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Welfare Benefit Premiums Paid to Carrier	USD $593,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

5955479

Policy instance

Insurance contract or identification number	5955479
Number of Individuals Covered	678
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $36,567
Total amount of fees paid to insurance company	USD $24
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $324,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,566
Insurance broker organization code?	3
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION

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

Policy contract number

0219896

Policy instance

Insurance contract or identification number	0219896
Number of Individuals Covered	169
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,778
Total amount of fees paid to insurance company	USD $24
Other welfare benefits provided	CRITICAL ILLNESS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $29,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,428
Insurance broker organization code?	3
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	560
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $23,951
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 $20,766
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	6
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,471
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 $3,009
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	177
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $33,238
Temporary 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 $28,777
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

CV785

Policy instance

Insurance contract or identification number	CV785
Number of Individuals Covered	56
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,321
Total amount of fees paid to insurance company	USD $426
Other welfare benefits provided	CANCER, INTENSIVE CARE, & RECOVERY
Welfare Benefit Premiums Paid to Carrier	USD $56,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,195
Amount paid for insurance broker fees	304
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES OR FORMS OF NON-MONETARY COMPENSATION.
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	387
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $91,044
Welfare Benefit Premiums Paid to Carrier	USD $611,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $91,044
Insurance broker organization code?	3

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

Policy contract number

5955479

Policy instance

Insurance contract or identification number	5955479
Number of Individuals Covered	706
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $37,131
Total amount of fees paid to insurance company	USD $6,252
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $310,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,015
Amount paid for insurance broker fees	6252
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

0219896

Policy instance

Insurance contract or identification number	0219896
Number of Individuals Covered	159
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,846
Total amount of fees paid to insurance company	USD $531
Other welfare benefits provided	CRITICAL ILLNESS INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $26,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,744
Amount paid for insurance broker fees	531
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	581
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $20,960
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 $20,960
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	7
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,952
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 $2,952
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	169
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $25,101
Temporary 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 $25,101
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

CV785

Policy instance

Insurance contract or identification number	CV785
Number of Individuals Covered	71
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,835
Total amount of fees paid to insurance company	USD $30
Other welfare benefits provided	CANCER, INTENSIVE CARE, & RECOVERY
Welfare Benefit Premiums Paid to Carrier	USD $55,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,181
Amount paid for insurance broker fees	22
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES OR FORMS OF NON-MONETARY COMPENSATION.
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	408
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $90,290
Welfare Benefit Premiums Paid to Carrier	USD $607,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $90,290
Insurance broker organization code?	3

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

Policy contract number

5955479

Policy instance

Insurance contract or identification number	5955479
Number of Individuals Covered	696
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $28,399
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $311,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,399
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	6
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,996
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 $2,996
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	629
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $18,107
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 $18,107
Insurance broker organization code?	3

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
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 $24,041
Temporary 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 $24,041
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

CV785

Policy instance

Insurance contract or identification number	CV785
Number of Individuals Covered	81
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,772
Total amount of fees paid to insurance company	USD $184
Other welfare benefits provided	CANCER, INTENSIVE CARE, & RECOVERY
Welfare Benefit Premiums Paid to Carrier	USD $70,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,426
Amount paid for insurance broker fees	132
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES OR FORMS OF NON-MONETARY COMPENSATION.
Insurance broker organization code?	3

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

Policy contract number

30040701

Policy instance

Insurance contract or identification number	30040701
Number of Individuals Covered	317
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,361
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,361
Insurance broker organization code?	3

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

Policy contract number

0000011363

Policy instance

Insurance contract or identification number	0000011363
Number of Individuals Covered	32
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,697
Other welfare benefits provided	CRITICAL ILLNESS PLAN
Welfare Benefit Premiums Paid to Carrier	USD $8,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $380
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	442
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $86,917
Welfare Benefit Premiums Paid to Carrier	USD $582,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $86,917
Insurance broker organization code?	3

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

Policy contract number

0000011363

Policy instance

Insurance contract or identification number	0000011363
Number of Individuals Covered	32
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,026
Other welfare benefits provided	CRITICAL ILLNESS PLAN
Welfare Benefit Premiums Paid to Carrier	USD $10,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $481
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

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

Policy contract number

30040701

Policy instance

Insurance contract or identification number	30040701
Number of Individuals Covered	298
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,459
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,459
Insurance broker organization code?	3
Insurance broker name	TODD E. PETER

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

CV785

Policy instance

Insurance contract or identification number	CV785
Number of Individuals Covered	81
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9,504
Total amount of fees paid to insurance company	USD $175
Other welfare benefits provided	CANCER, INTENSIVE CARE, & RECOVERY
Welfare Benefit Premiums Paid to Carrier	USD $65,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,068
Amount paid for insurance broker fees	125
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES OR FORMS OF NON-MONETARY COMPENSATION.
Insurance broker organization code?	3
Insurance broker name	JOE A DEPASQUAL

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	170
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $26,081
Temporary 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 $26,081
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	440
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $72,439
Welfare Benefit Premiums Paid to Carrier	USD $531,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $72,439
Insurance broker organization code?	3
Insurance broker name	HIGGINBOTHAM INSURANCE AGENCY

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,088
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 $3,088
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	626
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $18,700
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 $18,700
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	90
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,031
Total amount of fees paid to insurance company	USD $100
Other welfare benefits provided	CANCER, INTENSIVE CARE, & RECOVERY
Welfare Benefit Premiums Paid to Carrier	USD $77,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,862
Amount paid for insurance broker fees	63
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES OR OTHER FORMS OF NON-MONETARY COMPENSATION.
Insurance broker organization code?	3
Insurance broker name	GEORGIA ANN KNABE

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	159
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $19,611
Temporary 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 $19,611
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	8
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,854
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 $2,854
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	550
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $12,372
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 $12,372
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

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

Policy contract number

30040701

Policy instance

Insurance contract or identification number	30040701
Number of Individuals Covered	232
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,416
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $34,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,416
Insurance broker organization code?	3
Insurance broker name	TODD E. PETER

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	436
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $71,172
Welfare Benefit Premiums Paid to Carrier	USD $421,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,314
Insurance broker organization code?	3
Insurance broker name	HIGGINBOTHAM INSURANCE AGENCY

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	549
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $13,358
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 $13,358
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	21
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,849
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 $2,849
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	392
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $44,198
Welfare Benefit Premiums Paid to Carrier	USD $356,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,198
Insurance broker organization code?	3
Insurance broker name	HIGGINBOTHAM INSURANCE AGENCY

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	150
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $19,335
Temporary 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 $19,335
Insurance broker organization code?	3
Insurance broker name	TODD E PETER

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

58-0663085

Policy instance

Insurance contract or identification number	58-0663085
Number of Individuals Covered	99
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,599
Total amount of fees paid to insurance company	USD $66
Other welfare benefits provided	CANCER, INTENSIVE CARE, & RECOVERY
Welfare Benefit Premiums Paid to Carrier	USD $72,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,684
Amount paid for insurance broker fees	42
Additional information about fees paid to insurance broker	FEES, AWARDS, PRIZES, BONUSES OR OTHER FORMS OF NON-MONETARY COMPENSATION.
Insurance broker organization code?	3
Insurance broker name	JOHN SHELBY AMOS

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

Policy contract number

30040701

Policy instance

Insurance contract or identification number	30040701
Number of Individuals Covered	213
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,892
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,892
Insurance broker organization code?	3
Insurance broker name	TODD E. PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	14
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $241
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 $241
Insurance broker organization code?	3
Insurance broker name	TODD PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	509
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $9,259
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,259
Insurance broker organization code?	3
Insurance broker name	TODD PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	146
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $16,706
Temporary 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 $16,706
Insurance broker organization code?	3
Insurance broker name	TODD PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,361
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,361
Insurance broker organization code?	3
Insurance broker name	TODD PETER

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0839580

Policy instance

Insurance contract or identification number	0839580
Number of Individuals Covered	345
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $47,252
Total amount of fees paid to insurance company	USD $2,500
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 $47,252
Amount paid for insurance broker fees	2500
Additional information about fees paid to insurance broker	ASA SUPREME BONUS PROGRAM - 2013
Insurance broker organization code?	3
Insurance broker name	HIGGINBOTHAM INSURANCE AGENCY

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	152
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $18,177
Temporary 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 $18,177
Insurance broker organization code?	3
Insurance broker name	TODD PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	171
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,223
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,223
Insurance broker organization code?	3
Insurance broker name	TODD PETER

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

65983-5

Policy instance

Insurance contract or identification number	65983-5
Number of Individuals Covered	829
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $44,027
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $293,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,027
Additional information about fees paid to insurance broker	WRITING AGENT
Insurance broker organization code?	3
Insurance broker name	HIGGINBOTHAM INSURANCE AGENCY

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

CV785

Policy instance

Insurance contract or identification number	CV785
Number of Individuals Covered	121
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $15,887
Total amount of fees paid to insurance company	USD $25
Other welfare benefits provided	OTHER WELFARE BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $105,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,635
Amount paid for insurance broker fees	16
Insurance broker organization code?	3
Insurance broker name	STEVE WHITTEN

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	525
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $10,297
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 $10,297
Insurance broker organization code?	3
Insurance broker name	TODD PETER

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	153
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $17,664
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	562
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $10,311
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	140
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,638
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

CV785

Policy instance

Insurance contract or identification number	CV785
Number of Individuals Covered	137
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $15,929
Total amount of fees paid to insurance company	USD $848
Welfare Benefit Premiums Paid to Carrier	USD $111,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

65983-5

Policy instance

Insurance contract or identification number	65983-5
Number of Individuals Covered	394
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $48,461
Welfare Benefit Premiums Paid to Carrier	USD $323,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	137
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $17,032
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

65983-5

Policy instance

Insurance contract or identification number	65983-5
Number of Individuals Covered	416
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $41,125
Welfare Benefit Premiums Paid to Carrier	USD $274,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	129
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,559
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

645044

Policy instance

Insurance contract or identification number	645044
Number of Individuals Covered	562
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $10,517
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	HILL COUNTRY MEMORIAL HOSPITAL
Employer identification number (EIN):	746083124
NAIC Classification:	622000
NAIC Description:	Hospitals

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	1966-12-07
Company Identification Number:	0022997201
Legal Registered Office Address:	PO BOX 835 FREDERICKSBRG United States of America (USA) 78624