401k Plan data: POTTER CONCRETE CAFETERIA PLAN plan

POTTER CONCRETE CAFETERIA PLAN 401k Plan overview

Plan Name	POTTER CONCRETE CAFETERIA PLAN
Plan identification number	501

POTTER CONCRETE CAFETERIA PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Temporary disability (accident and sickness)

401k Sponsoring company profile

POTTER CONCRETE, LTD. has sponsored the creation of one or more 401k plans.

Company Name: POTTER CONCRETE, LTD.

Employer identification number (EIN): 752908373

NAIC Classification: 238100

Additional information about POTTER CONCRETE, LTD.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2000-11-01

Company Identification Number: 0014170510

Legal Registered Office Address: 2400 E PIONEER DR

IRVING
United States of America (USA)
75061

More information about POTTER CONCRETE, LTD.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan POTTER CONCRETE CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-10-01 ROB GRAHAM 2024-04-18
501 2021-10-01 JOHN C CAFFEY 2023-03-31
501 2020-10-01 JOHN C. CAFFEY 2022-04-27
501 2019-10-01 JOHN C. CAFFEY 2021-04-26
501 2018-10-01 JOHN C. CAFFEY 2020-04-08
501 2017-10-01 JOHN C. CAFFEY 2019-04-30
501 2016-10-01
501 2015-10-01
501 2015-10-01 JOHN C.CAFFEY 2017-04-28
501 2014-10-01
501 2014-01-01 JOHN C. CAFFEY JOHN C. CAFFEY 2015-06-17
501 2013-01-01 JOHN C. CAFFEY JOHN C. CAFFEY 2014-07-24
501 2012-01-01 JOHN C. CAFFEY JOHN C. CAFFEY 2013-06-20
501 2011-01-01 JOHN C. CAFFEY JOHN C. CAFFEY 2012-07-31
501 2009-01-01 JOHN C.CAFFEY JOHN C. CAFFEY 2010-10-14

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-10-01	ROB GRAHAM	2024-04-18
501	2021-10-01	JOHN C CAFFEY	2023-03-31
501	2020-10-01	JOHN C. CAFFEY	2022-04-27
501	2019-10-01	JOHN C. CAFFEY	2021-04-26
501	2018-10-01	JOHN C. CAFFEY	2020-04-08
501	2017-10-01	JOHN C. CAFFEY	2019-04-30
501	2016-10-01
501	2015-10-01
501	2015-10-01	JOHN C.CAFFEY	2017-04-28
501	2014-10-01
501	2014-01-01	JOHN C. CAFFEY		JOHN C. CAFFEY	2015-06-17
501	2013-01-01	JOHN C. CAFFEY		JOHN C. CAFFEY	2014-07-24
501	2012-01-01	JOHN C. CAFFEY		JOHN C. CAFFEY	2013-06-20
501	2011-01-01	JOHN C. CAFFEY		JOHN C. CAFFEY	2012-07-31
501	2009-01-01	JOHN C.CAFFEY		JOHN C. CAFFEY	2010-10-14

Plan Statistics for POTTER CONCRETE CAFETERIA PLAN

401k plan membership statisitcs for POTTER CONCRETE CAFETERIA PLAN

Measure Date Value
2022: POTTER CONCRETE CAFETERIA PLAN 2022 401k membership
Total participants, beginning-of-year 2022-10-01 332
Total number of active participants reported on line 7a of the Form 5500 2022-10-01 342
Total of all active and inactive participants 2022-10-01 342
2021: POTTER CONCRETE CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year 2021-10-01 354
Total number of active participants reported on line 7a of the Form 5500 2021-10-01 332
Total of all active and inactive participants 2021-10-01 332
2020: POTTER CONCRETE CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year 2020-10-01 491
Total number of active participants reported on line 7a of the Form 5500 2020-10-01 354
Total of all active and inactive participants 2020-10-01 354
2019: POTTER CONCRETE CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 599
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 491
Total of all active and inactive participants 2019-10-01 491
2018: POTTER CONCRETE CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year 2018-10-01 602
Total number of active participants reported on line 7a of the Form 5500 2018-10-01 599
Total of all active and inactive participants 2018-10-01 599
2017: POTTER CONCRETE CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year 2017-10-01 397
Total number of active participants reported on line 7a of the Form 5500 2017-10-01 602
Total of all active and inactive participants 2017-10-01 602
2016: POTTER CONCRETE CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year 2016-10-01 486
Total number of active participants reported on line 7a of the Form 5500 2016-10-01 397
Total of all active and inactive participants 2016-10-01 397
2015: POTTER CONCRETE CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year 2015-10-01 595
Total number of active participants reported on line 7a of the Form 5500 2015-10-01 486
Total of all active and inactive participants 2015-10-01 486
2014: POTTER CONCRETE CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year 2014-10-01 258
Total number of active participants reported on line 7a of the Form 5500 2014-10-01 595
Total of all active and inactive participants 2014-10-01 595
Total participants, beginning-of-year 2014-01-01 265
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 258
Total of all active and inactive participants 2014-01-01 258
2013: POTTER CONCRETE CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 265
Total of all active and inactive participants 2013-01-01 265
2012: POTTER CONCRETE CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 207
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 145
Total of all active and inactive participants 2012-01-01 145
2011: POTTER CONCRETE CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 241
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 207
Total of all active and inactive participants 2011-01-01 207
2009: POTTER CONCRETE CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 509
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 326
Total of all active and inactive participants 2009-01-01 326

Measure	Date	Value
2022: POTTER CONCRETE CAFETERIA PLAN 2022 401k membership
Total participants, beginning-of-year	2022-10-01	332
Total number of active participants reported on line 7a of the Form 5500	2022-10-01	342
Total of all active and inactive participants	2022-10-01	342
2021: POTTER CONCRETE CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year	2021-10-01	354
Total number of active participants reported on line 7a of the Form 5500	2021-10-01	332
Total of all active and inactive participants	2021-10-01	332
2020: POTTER CONCRETE CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year	2020-10-01	491
Total number of active participants reported on line 7a of the Form 5500	2020-10-01	354
Total of all active and inactive participants	2020-10-01	354
2019: POTTER CONCRETE CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	599
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	491
Total of all active and inactive participants	2019-10-01	491
2018: POTTER CONCRETE CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year	2018-10-01	602
Total number of active participants reported on line 7a of the Form 5500	2018-10-01	599
Total of all active and inactive participants	2018-10-01	599
2017: POTTER CONCRETE CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year	2017-10-01	397
Total number of active participants reported on line 7a of the Form 5500	2017-10-01	602
Total of all active and inactive participants	2017-10-01	602
2016: POTTER CONCRETE CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year	2016-10-01	486
Total number of active participants reported on line 7a of the Form 5500	2016-10-01	397
Total of all active and inactive participants	2016-10-01	397
2015: POTTER CONCRETE CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year	2015-10-01	595
Total number of active participants reported on line 7a of the Form 5500	2015-10-01	486
Total of all active and inactive participants	2015-10-01	486
2014: POTTER CONCRETE CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year	2014-10-01	258
Total number of active participants reported on line 7a of the Form 5500	2014-10-01	595
Total of all active and inactive participants	2014-10-01	595
Total participants, beginning-of-year	2014-01-01	265
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	258
Total of all active and inactive participants	2014-01-01	258
2013: POTTER CONCRETE CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	265
Total of all active and inactive participants	2013-01-01	265
2012: POTTER CONCRETE CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	207
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	145
Total of all active and inactive participants	2012-01-01	145
2011: POTTER CONCRETE CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	241
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	207
Total of all active and inactive participants	2011-01-01	207
2009: POTTER CONCRETE CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	509
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	326
Total of all active and inactive participants	2009-01-01	326

Form 5500 Responses for POTTER CONCRETE CAFETERIA PLAN

2022: POTTER CONCRETE CAFETERIA PLAN 2022 form 5500 responses
2022-10-01	Type of plan entity	Single employer plan
2022-10-01	Plan funding arrangement – Insurance	Yes
2022-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-10-01	Plan benefit arrangement – Insurance	Yes
2022-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: POTTER CONCRETE CAFETERIA PLAN 2021 form 5500 responses
2021-10-01	Type of plan entity	Single employer plan
2021-10-01	Plan funding arrangement – Insurance	Yes
2021-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-10-01	Plan benefit arrangement – Insurance	Yes
2021-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: POTTER CONCRETE CAFETERIA PLAN 2020 form 5500 responses
2020-10-01	Type of plan entity	Single employer plan
2020-10-01	Plan funding arrangement – Insurance	Yes
2020-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-10-01	Plan benefit arrangement – Insurance	Yes
2020-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: POTTER CONCRETE CAFETERIA PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: POTTER CONCRETE CAFETERIA PLAN 2018 form 5500 responses
2018-10-01	Type of plan entity	Single employer plan
2018-10-01	Plan funding arrangement – Insurance	Yes
2018-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-10-01	Plan benefit arrangement – Insurance	Yes
2018-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: POTTER CONCRETE CAFETERIA PLAN 2017 form 5500 responses
2017-10-01	Type of plan entity	Single employer plan
2017-10-01	Plan funding arrangement – Insurance	Yes
2017-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-10-01	Plan benefit arrangement – Insurance	Yes
2017-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: POTTER CONCRETE CAFETERIA PLAN 2016 form 5500 responses
2016-10-01	Type of plan entity	Single employer plan
2016-10-01	Plan funding arrangement – Insurance	Yes
2016-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-10-01	Plan benefit arrangement – Insurance	Yes
2016-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: POTTER CONCRETE CAFETERIA PLAN 2015 form 5500 responses
2015-10-01	Type of plan entity	Single employer plan
2015-10-01	Submission has been amended	Yes
2015-10-01	Plan funding arrangement – Insurance	Yes
2015-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-10-01	Plan benefit arrangement – Insurance	Yes
2015-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: POTTER CONCRETE CAFETERIA PLAN 2014 form 5500 responses
2014-10-01	Type of plan entity	Single employer plan
2014-10-01	Plan funding arrangement – Insurance	Yes
2014-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-10-01	Plan benefit arrangement – Insurance	Yes
2014-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: POTTER CONCRETE CAFETERIA PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: POTTER CONCRETE CAFETERIA PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: POTTER CONCRETE CAFETERIA 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 benefit arrangement – Insurance	Yes
2009: POTTER CONCRETE CAFETERIA PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

309425

Policy instance

Insurance contract or identification number	309425
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $3,682
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $37,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,682
Insurance broker organization code?	3

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

Policy contract number

919112

Policy instance

Insurance contract or identification number	919112
Number of Individuals Covered	429
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $17,732
Total amount of fees paid to insurance company	USD $94,267
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,900,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,732
Amount paid for insurance broker fees	94267
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	330
Insurance policy start date	2022-10-01
Insurance policy end date	2023-09-30
Total amount of commissions paid to insurance broker	USD $130,276
Total amount of fees paid to insurance company	USD $30,629
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $654,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $58,782
Amount paid for insurance broker fees	8634
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

309425

Policy instance

Insurance contract or identification number	309425
Number of Individuals Covered	204
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $3,239
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $18,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,239
Insurance broker organization code?	3

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

Policy contract number

919112

Policy instance

Insurance contract or identification number	919112
Number of Individuals Covered	403
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $17,824
Total amount of fees paid to insurance company	USD $96,627
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,884,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,824
Amount paid for insurance broker fees	96627
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	321
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $149,970
Total amount of fees paid to insurance company	USD $40,645
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $699,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67,636
Amount paid for insurance broker fees	3705
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

916560

Policy instance

Insurance contract or identification number	916560
Number of Individuals Covered	218
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $16,901
Total amount of fees paid to insurance company	USD $863
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $128,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,901
Amount paid for insurance broker fees	863
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

919112

Policy instance

Insurance contract or identification number	919112
Number of Individuals Covered	481
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $92,284
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,754,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	92284
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	349
Insurance policy start date	2020-10-01
Insurance policy end date	2021-09-30
Total amount of commissions paid to insurance broker	USD $175,893
Total amount of fees paid to insurance company	USD $45,479
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $734,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $79,006
Amount paid for insurance broker fees	4516
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	373
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $152,708
Total amount of fees paid to insurance company	USD $38,208
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $779,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $66,128
Amount paid for insurance broker fees	10631
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

916560

Policy instance

Insurance contract or identification number	916560
Number of Individuals Covered	210
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $17,221
Total amount of fees paid to insurance company	USD $521
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $129,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,221
Amount paid for insurance broker fees	521
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

919112

Policy instance

Insurance contract or identification number	919112
Number of Individuals Covered	318
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $68,061
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,798,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	68061
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

WESTPOINT INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 39845 )

Policy contract number

1000853-02

Policy instance

Insurance contract or identification number	1000853-02
Number of Individuals Covered	144
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $3,185
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $46,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,185
Insurance broker organization code?	3

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	421
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $146,123
Total amount of fees paid to insurance company	USD $28,538
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $555,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $63,163
Amount paid for insurance broker fees	5614
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00620024

Policy instance

Insurance contract or identification number	00620024
Number of Individuals Covered	253
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $94,530
Total amount of fees paid to insurance company	USD $-49,111
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $943,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $94,530
Amount paid for insurance broker fees	-49111
Additional information about fees paid to insurance broker	ADMINISTRATION FEES
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

916560

Policy instance

Insurance contract or identification number	916560
Number of Individuals Covered	235
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $17,389
Total amount of fees paid to insurance company	USD $302
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $133,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,389
Amount paid for insurance broker fees	302
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00620024

Policy instance

Insurance contract or identification number	00620024
Number of Individuals Covered	242
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $92,488
Total amount of fees paid to insurance company	USD $23,921
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $912,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	374
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $108,143
Total amount of fees paid to insurance company	USD $33,346
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $516,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	18
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $629
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	224
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $15,978
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $119,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

WESTPOINT INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 39845 )

Policy contract number

1200040-00

Policy instance

Insurance contract or identification number	1200040-00
Number of Individuals Covered	261
Insurance policy start date	2017-10-01
Insurance policy end date	2018-09-30
Total amount of commissions paid to insurance broker	USD $1,135
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $32,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

00802-15

Policy instance

Insurance contract or identification number	00802-15
Number of Individuals Covered	153
Insurance policy start date	2015-10-01
Insurance policy end date	2016-09-30
Total amount of commissions paid to insurance broker	USD $6,245
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $73,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7979206

Policy instance

Insurance contract or identification number	E7979206
Number of Individuals Covered	51
Insurance policy start date	2015-10-01
Insurance policy end date	2016-09-30
Total amount of commissions paid to insurance broker	USD $5,969
Total amount of fees paid to insurance company	USD $1,408
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $5,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	266
Insurance policy start date	2015-10-01
Insurance policy end date	2016-09-30
Total amount of commissions paid to insurance broker	USD $17,272
Total amount of fees paid to insurance company	USD $5,130
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $127,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	39
Insurance policy start date	2015-10-01
Insurance policy end date	2016-09-30
Total amount of commissions paid to insurance broker	USD $1,075
Total amount of fees paid to insurance company	USD $337
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0903296

Policy instance

Insurance contract or identification number	0903296
Number of Individuals Covered	312
Insurance policy start date	2015-10-01
Insurance policy end date	2016-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $69,865
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,328,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0903296

Policy instance

Insurance contract or identification number	0903296
Number of Individuals Covered	206
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $64,583
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,292,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	64583
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	298
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $25,656
Total amount of fees paid to insurance company	USD $228
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY DENTAL & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $181,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,656
Amount paid for insurance broker fees	228
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	42
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $945
Total amount of fees paid to insurance company	USD $12
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $945
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	MARSH & MCLENNAN AGENCY, LLC

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

Policy contract number

E7979206

Policy instance

Insurance contract or identification number	E7979206
Number of Individuals Covered	352
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $74,299
Total amount of fees paid to insurance company	USD $18,322
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $207,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $30,499
Amount paid for insurance broker fees	3705
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	RAYMOND ROBERTS SEIFERT, JR

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	639
Insurance policy start date	2014-10-01
Insurance policy end date	2015-09-30
Total amount of commissions paid to insurance broker	USD $15,036
Total amount of fees paid to insurance company	USD $4,603
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $39,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,163
Amount paid for insurance broker fees	772
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	REBECCA G DEJESUS

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	11
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $1,219
Total amount of fees paid to insurance company	USD $232
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $12,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $313
Amount paid for insurance broker fees	26
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	DONNELL EUGENE STANLEY

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

Policy contract number

E7979206

Policy instance

Insurance contract or identification number	E7979206
Number of Individuals Covered	132
Insurance policy start date	2013-10-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $35,363
Total amount of fees paid to insurance company	USD $6,276
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $116,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,413
Amount paid for insurance broker fees	863
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	DAVID EVANS

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	182
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $16,386
Total amount of fees paid to insurance company	USD $4,397
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY DENTAL & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $113,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,386
Amount paid for insurance broker fees	4397
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	PRESCOTT PAILET BEN A MARSH & MCLEN

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	42
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $911
Total amount of fees paid to insurance company	USD $226
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $911
Amount paid for insurance broker fees	226
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	PRESCOTT PAILET BEN A MARSH & MCLEN

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	13
Insurance policy start date	2013-07-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $363
Total amount of fees paid to insurance company	USD $35
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $3,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $153
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	DONNELL EUGENE STANLEY

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

Policy contract number

E7979206

Policy instance

Insurance contract or identification number	E7979206
Number of Individuals Covered	193
Insurance policy start date	2013-07-01
Insurance policy end date	2013-09-30
Total amount of commissions paid to insurance broker	USD $3,890
Total amount of fees paid to insurance company	USD $344
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $7,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,594
Amount paid for insurance broker fees	124
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	DAVID EVANS

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 )

Policy contract number

0847508-SHORT

Policy instance

Insurance contract or identification number	0847508-SHORT
Number of Individuals Covered	230
Insurance policy start date	2014-04-01
Insurance policy end date	2014-09-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $454,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

714058

Policy instance

Insurance contract or identification number	714058
Number of Individuals Covered	208
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $37,796
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $724,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,796
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INDEPENDENT INS GROUP BENEFITS INC.

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	32
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $849
Total amount of fees paid to insurance company	USD $87
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $707
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	PRESCOTT PAILET BEN A MARSH & MCLEN

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

Policy contract number

E7979206

Policy instance

Insurance contract or identification number	E7979206
Number of Individuals Covered	75
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $6,951
Total amount of fees paid to insurance company	USD $1,171
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $38,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,438
Amount paid for insurance broker fees	230
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	DAVID EVANS

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	14
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,786
Total amount of fees paid to insurance company	USD $395
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $14,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $633
Amount paid for insurance broker fees	60
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GRACIELA V FERNANDEZ-NEWELL

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	172
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $15,102
Total amount of fees paid to insurance company	USD $1,570
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY DENTAL & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $104,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,513
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	PRESCOTT PAILET BEN A MARSH & MCLEN

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

Policy contract number

E7979206

Policy instance

Insurance contract or identification number	E7979206
Number of Individuals Covered	92
Insurance policy start date	2011-05-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $11,512
Total amount of fees paid to insurance company	USD $2,053
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $36,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,339
Amount paid for insurance broker fees	215
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	MARTHA GUTIERREZ

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	16
Insurance policy start date	2011-05-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $2,085
Total amount of fees paid to insurance company	USD $466
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $16,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $882
Amount paid for insurance broker fees	42
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	FRANCISCO X CABRERA

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

Policy contract number

714058

Policy instance

Insurance contract or identification number	714058
Number of Individuals Covered	262
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $24,066
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $741,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,066
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	INDEPENDENT INS GROUP BEN INC.

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	179
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $14,555
Total amount of fees paid to insurance company	USD $760
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY DENTAL & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $100,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,555
Amount paid for insurance broker fees	760
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	INDEPENDENT INS GROUP BEN INC.

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	29
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $679
Total amount of fees paid to insurance company	USD $35
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $679
Amount paid for insurance broker fees	35
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	INDEPENDENT INS GROUP BEN INC.

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

Policy contract number

0714058

Policy instance

Insurance contract or identification number	0714058
Number of Individuals Covered	229
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $41,682
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $833,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	81
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $7,764
Total amount of fees paid to insurance company	USD $501
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $52,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	16
Insurance policy start date	2010-05-01
Insurance policy end date	2011-04-30
Total amount of commissions paid to insurance broker	USD $1,950
Total amount of fees paid to insurance company	USD $233
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $22,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

E7979206

Policy instance

Insurance contract or identification number	E7979206
Number of Individuals Covered	51
Insurance policy start date	2010-05-01
Insurance policy end date	2011-04-30
Total amount of commissions paid to insurance broker	USD $2,284
Total amount of fees paid to insurance company	USD $246
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $25,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	19
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $561
Total amount of fees paid to insurance company	USD $52
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

00040E001000

Policy instance

Insurance contract or identification number	00040E001000
Number of Individuals Covered	70
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $5,733
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $38,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010102312

Policy instance

Insurance contract or identification number	000010102312
Number of Individuals Covered	144
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $1,266
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

0714058

Policy instance

Insurance contract or identification number	0714058
Number of Individuals Covered	305
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $49,269
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $985,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,269
Insurance broker name	INDEPENDENT INS GROUP BEN INC.

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	107
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $11,306
Total amount of fees paid to insurance company	USD $539
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY DENTAL
Welfare Benefit Premiums Paid to Carrier	USD $75,373
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,306
Amount paid for insurance broker fees	539
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	INDEPENDENT INS GROUP BEN INC.

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

Policy contract number

E3091337

Policy instance

Insurance contract or identification number	E3091337
Number of Individuals Covered	44
Insurance policy start date	2009-04-02
Insurance policy end date	2010-04-01
Total amount of commissions paid to insurance broker	USD $5,471
Total amount of fees paid to insurance company	USD $386
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $35,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,163
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	DAVID EVANS

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

Policy contract number

E7979206

Policy instance

Insurance contract or identification number	E7979206
Number of Individuals Covered	45
Insurance policy start date	2009-04-02
Insurance policy end date	2010-04-01
Total amount of commissions paid to insurance broker	USD $2,212
Total amount of fees paid to insurance company	USD $133
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY SUPPLEMENTAL
Welfare Benefit Premiums Paid to Carrier	USD $20,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $940
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS
Insurance broker name	DAVID EVANS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

00040E001000

Policy instance

Insurance contract or identification number	00040E001000
Number of Individuals Covered	81
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $8,791
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	VOLUNTARY LIFE & AD&D
Welfare Benefit Premiums Paid to Carrier	USD $58,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,791
Insurance broker organization code?	3
Insurance broker name	INDEPENDENT INS GROUP BEN INC.

UNITED DENTAL CARE OF TEXAS INC (National Association of Insurance Commissioners NAIC id number: 95142 )

Policy contract number

5426784

Policy instance

Insurance contract or identification number	5426784
Number of Individuals Covered	10
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $379
Total amount of fees paid to insurance company	USD $27
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $379
Amount paid for insurance broker fees	27
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	INDEPENDENT INS GROUP BEN INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )

Policy contract number

000010102312

Policy instance

Insurance contract or identification number	000010102312
Number of Individuals Covered	166
Insurance policy start date	2009-04-01
Insurance policy end date	2010-03-31
Total amount of commissions paid to insurance broker	USD $1,988
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,988
Insurance broker organization code?	3
Insurance broker name	INDEPENDENT INS GROUP BEN INC.

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Company Name:	POTTER CONCRETE, LTD.
Employer identification number (EIN):	752908373
NAIC Classification:	238100

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2000-11-01
Company Identification Number:	0014170510
Legal Registered Office Address:	2400 E PIONEER DR IRVING United States of America (USA) 75061