401k Plan data: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN plan

DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN
Plan identification number	501

DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

DEARBORN HOLDING COMPANY, LLC has sponsored the creation of one or more 401k plans.

Company Name: DEARBORN HOLDING COMPANY, LLC

Employer identification number (EIN): 811151147

NAIC Classification: 238900

Additional information about DEARBORN HOLDING COMPANY, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 5934294

More information about DEARBORN HOLDING COMPANY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 KELLY SCHAFER
501 2017-01-01 KELLY SCHAFER
501 2016-01-01 KELLY SCHAFER

Plan Statistics for DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN

Measure Date Value
2023: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 320
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 332
Number of retired or separated participants receiving benefits 2023-01-01 3
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 335
2022: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 289
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 319
Number of retired or separated participants receiving benefits 2022-01-01 3
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 322
2021: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 243
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 285
Number of retired or separated participants receiving benefits 2021-01-01 3
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 288
2020: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 269
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 240
Number of retired or separated participants receiving benefits 2020-01-01 7
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 247
2019: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 267
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 263
Number of retired or separated participants receiving benefits 2019-01-01 6
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 269
2018: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 249
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 263
Number of retired or separated participants receiving benefits 2018-01-01 4
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 267
2017: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 253
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 246
Number of retired or separated participants receiving benefits 2017-01-01 7
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 253
2016: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 136
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 127
Number of retired or separated participants receiving benefits 2016-01-01 8
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 135

Measure	Date	Value
2023: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	320
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	332
Number of retired or separated participants receiving benefits	2023-01-01	3
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	335
2022: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	289
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	319
Number of retired or separated participants receiving benefits	2022-01-01	3
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	322
2021: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	243
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	285
Number of retired or separated participants receiving benefits	2021-01-01	3
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	288
2020: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	269
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	240
Number of retired or separated participants receiving benefits	2020-01-01	7
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	247
2019: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	267
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	263
Number of retired or separated participants receiving benefits	2019-01-01	6
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	269
2018: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	249
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	263
Number of retired or separated participants receiving benefits	2018-01-01	4
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	267
2017: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	253
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	246
Number of retired or separated participants receiving benefits	2017-01-01	7
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	253
2016: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	136
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	127
Number of retired or separated participants receiving benefits	2016-01-01	8
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	135

Form 5500 Responses for DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN

2023: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: DEARBORN HOLDING COMPANY, LLC EMPLOYEE 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: DEARBORN HOLDING COMPANY, LLC EMPLOYEE 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: DEARBORN HOLDING COMPANY, LLC EMPLOYEE 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 benefit arrangement – Insurance	Yes
2019: DEARBORN HOLDING COMPANY, LLC EMPLOYEE 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 benefit arrangement – Insurance	Yes
2018: DEARBORN HOLDING COMPANY, LLC EMPLOYEE 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 benefit arrangement – Insurance	Yes
2017: DEARBORN HOLDING COMPANY, LLC EMPLOYEE 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 benefit arrangement – Insurance	Yes
2016: DEARBORN HOLDING COMPANY, LLC EMPLOYEE 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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

4EL-6656

Policy instance

Insurance contract or identification number	4EL-6656
Number of Individuals Covered	358
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $632
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10002562

Policy instance

Insurance contract or identification number	10002562
Number of Individuals Covered	64
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $22,391
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $466,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

ETB131007

Policy instance

Insurance contract or identification number	ETB131007
Number of Individuals Covered	296
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $319
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

286856

Policy instance

Insurance contract or identification number	286856
Number of Individuals Covered	374
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $11,582
Total amount of fees paid to insurance company	USD $57,216
Welfare Benefit Premiums Paid to Carrier	USD $290,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

202926

Policy instance

Insurance contract or identification number	202926
Number of Individuals Covered	101
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,036
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $14,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609220

Policy instance

Insurance contract or identification number	609220
Number of Individuals Covered	248
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $23,427
Total amount of fees paid to insurance company	USD $2,857
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $228,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

444751

Policy instance

Insurance contract or identification number	444751
Number of Individuals Covered	298
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,652
Total amount of fees paid to insurance company	USD $1,666
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $133,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

444750

Policy instance

Insurance contract or identification number	444750
Number of Individuals Covered	135
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $15,365
Total amount of fees paid to insurance company	USD $1,281
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $102,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MARQUEE HEALTH (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

Policy instance

Insurance contract or identification number	1
Number of Individuals Covered	331
Insurance policy start date	2023-03-01
Insurance policy end date	2023-12-31
Other welfare benefits provided	WELLNESS
Welfare Benefit Premiums Paid to Carrier	USD $12,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

4EL-6656

Policy instance

Insurance contract or identification number	4EL-6656
Number of Individuals Covered	357
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $464
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $464
Insurance broker organization code?	3

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

Policy contract number

ETB131007

Policy instance

Insurance contract or identification number	ETB131007
Number of Individuals Covered	283
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $319
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $319
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10002562

Policy instance

Insurance contract or identification number	10002562
Number of Individuals Covered	68
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $19,884
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $452,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,278
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

286856

Policy instance

Insurance contract or identification number	286856
Number of Individuals Covered	355
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $11,346
Total amount of fees paid to insurance company	USD $50,317
Welfare Benefit Premiums Paid to Carrier	USD $257,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,346
Amount paid for insurance broker fees	48541
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

202926

Policy instance

Insurance contract or identification number	202926
Number of Individuals Covered	94
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,643
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $13,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,392
Insurance broker organization code?	4

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609220

Policy instance

Insurance contract or identification number	609220
Number of Individuals Covered	240
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,648
Total amount of fees paid to insurance company	USD $2,620
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $201,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,648
Amount paid for insurance broker fees	2620
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

444751

Policy instance

Insurance contract or identification number	444751
Number of Individuals Covered	280
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,654
Total amount of fees paid to insurance company	USD $1,906
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $116,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,654
Amount paid for insurance broker fees	1906
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

444750

Policy instance

Insurance contract or identification number	444750
Number of Individuals Covered	120
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,002
Total amount of fees paid to insurance company	USD $1,283
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $80,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,002
Amount paid for insurance broker fees	1283
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

286856

Policy instance

Insurance contract or identification number	286856
Number of Individuals Covered	301
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $10,220
Total amount of fees paid to insurance company	USD $43,731
Welfare Benefit Premiums Paid to Carrier	USD $318,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,220
Amount paid for insurance broker fees	42981
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

4EL-6656

Policy instance

Insurance contract or identification number	4EL-6656
Number of Individuals Covered	311
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $473
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $473
Insurance broker organization code?	3

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

Policy contract number

ETB131007

Policy instance

Insurance contract or identification number	ETB131007
Number of Individuals Covered	254
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $319
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $319
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10002562

Policy instance

Insurance contract or identification number	10002562
Number of Individuals Covered	64
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $19,398
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $454,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,398
Insurance broker organization code?	3

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

Policy contract number

97454151001

Policy instance

Insurance contract or identification number	97454151001
Number of Individuals Covered	338
Insurance policy start date	2021-01-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $948
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $948
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

202926

Policy instance

Insurance contract or identification number	202926
Number of Individuals Covered	86
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,905
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $12,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $956
Insurance broker organization code?	4

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609220

Policy instance

Insurance contract or identification number	609220
Number of Individuals Covered	206
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $16,854
Total amount of fees paid to insurance company	USD $2,257
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $165,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,854
Amount paid for insurance broker fees	2257
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

444750

Policy instance

Insurance contract or identification number	444750
Number of Individuals Covered	103
Insurance policy start date	2021-06-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,721
Total amount of fees paid to insurance company	USD $1,087
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $43,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,721
Amount paid for insurance broker fees	1087
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

444751

Policy instance

Insurance contract or identification number	444751
Number of Individuals Covered	244
Insurance policy start date	2021-06-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,737
Total amount of fees paid to insurance company	USD $1,694
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $67,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,737
Amount paid for insurance broker fees	1694
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0BJNW

Policy instance

Insurance contract or identification number	GVTL0BJNW
Number of Individuals Covered	76
Insurance policy start date	2021-01-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,677
Total amount of fees paid to insurance company	USD $3,229
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $20,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,677
Amount paid for insurance broker fees	3229
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0BJNW

Policy instance

Insurance contract or identification number	GLUG0BJNW
Number of Individuals Covered	213
Insurance policy start date	2021-01-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,936
Total amount of fees paid to insurance company	USD $3,598
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $24,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,936
Amount paid for insurance broker fees	3598
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD0BJNW

Policy instance

Insurance contract or identification number	GLTD0BJNW
Number of Individuals Covered	213
Insurance policy start date	2021-01-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $1,786
Total amount of fees paid to insurance company	USD $3,291
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,786
Amount paid for insurance broker fees	3291
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0BJNW

Policy instance

Insurance contract or identification number	GVTL0BJNW
Number of Individuals Covered	76
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,382
Total amount of fees paid to insurance company	USD $1,240
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $53,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,382
Amount paid for insurance broker fees	1240
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0BJNW

Policy instance

Insurance contract or identification number	GLUG0BJNW
Number of Individuals Covered	209
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,996
Total amount of fees paid to insurance company	USD $1,254
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $59,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,996
Amount paid for insurance broker fees	1254
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLTD0BJNW

Policy instance

Insurance contract or identification number	GLTD0BJNW
Number of Individuals Covered	209
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,484
Total amount of fees paid to insurance company	USD $1,156
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,484
Amount paid for insurance broker fees	1156
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609220

Policy instance

Insurance contract or identification number	609220
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 $12,190
Total amount of fees paid to insurance company	USD $2,156
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $121,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,190
Amount paid for insurance broker fees	2156
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

202926

Policy instance

Insurance contract or identification number	202926
Number of Individuals Covered	78
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,353
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $13,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,189
Insurance broker organization code?	4

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

34024

Policy instance

Insurance contract or identification number	34024
Number of Individuals Covered	301
Insurance policy start date	2020-01-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $3,761
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $805,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,761
Insurance broker organization code?	3

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

4EL-6656

Policy instance

Insurance contract or identification number	4EL-6656
Number of Individuals Covered	248
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $488
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $488
Insurance broker organization code?	3

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

Policy contract number

ETB131007

Policy instance

Insurance contract or identification number	ETB131007
Number of Individuals Covered	209
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $319
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $319
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10002562

Policy instance

Insurance contract or identification number	10002562
Number of Individuals Covered	66
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $22,303
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $451,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,303
Insurance broker organization code?	3

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

Policy contract number

665104

Policy instance

Insurance contract or identification number	665104
Number of Individuals Covered	9
Insurance policy start date	2020-01-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $520
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $520
Insurance broker organization code?	3

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

Policy contract number

97454151001

Policy instance

Insurance contract or identification number	97454151001
Number of Individuals Covered	356
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,365
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,365
Insurance broker organization code?	3

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

Policy contract number

ETB131007

Policy instance

Insurance contract or identification number	ETB131007
Number of Individuals Covered	229
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $319
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $319
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10002562

Policy instance

Insurance contract or identification number	10002562
Number of Individuals Covered	62
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $17,850
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $370,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,850
Insurance broker organization code?	3

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

Policy contract number

665104

Policy instance

Insurance contract or identification number	665104
Number of Individuals Covered	10
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,040
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $90,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,040
Insurance broker organization code?	3

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

Policy contract number

97454151001

Policy instance

Insurance contract or identification number	97454151001
Number of Individuals Covered	365
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,385
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,385
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1071183

Policy instance

Insurance contract or identification number	1071183
Number of Individuals Covered	404
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $2,903
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,903
Insurance broker organization code?	3

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

Policy contract number

5937695

Policy instance

Insurance contract or identification number	5937695
Number of Individuals Covered	412
Insurance policy start date	2019-01-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $8,928
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $441,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,928
Insurance broker organization code?	3

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

4EL-6656-18

Policy instance

Insurance contract or identification number	4EL-6656-18
Number of Individuals Covered	291
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $513
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $513
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

34024

Policy instance

Insurance contract or identification number	34024
Number of Individuals Covered	303
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $35,325
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,846,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,325
Insurance broker organization code?	3

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

Policy contract number

GVTL0BJNW

Policy instance

Insurance contract or identification number	GVTL0BJNW
Number of Individuals Covered	84
Insurance policy start date	2019-06-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,330
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $33,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,330
Insurance broker organization code?	3

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

Policy contract number

GLUG0BJNW

Policy instance

Insurance contract or identification number	GLUG0BJNW
Number of Individuals Covered	226
Insurance policy start date	2019-06-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,688
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $36,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,688
Insurance broker organization code?	3

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

Policy contract number

GLTD0BJNW

Policy instance

Insurance contract or identification number	GLTD0BJNW
Number of Individuals Covered	226
Insurance policy start date	2019-06-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,400
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,400
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

609220

Policy instance

Insurance contract or identification number	609220
Number of Individuals Covered	174
Insurance policy start date	2019-06-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $6,986
Total amount of fees paid to insurance company	USD $1,747
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $69,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,986
Amount paid for insurance broker fees	1747
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

202926

Policy instance

Insurance contract or identification number	202926
Number of Individuals Covered	328
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,069
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $13,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,192
Insurance broker organization code?	4

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1071183

Policy instance

Insurance contract or identification number	1071183
Number of Individuals Covered	424
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,252
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $131,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,252
Insurance broker organization code?	3

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

Policy contract number

97454151001

Policy instance

Insurance contract or identification number	97454151001
Number of Individuals Covered	376
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,411
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,411
Insurance broker organization code?	3

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

Policy contract number

665104

Policy instance

Insurance contract or identification number	665104
Number of Individuals Covered	10
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,840
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $130,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,840
Insurance broker organization code?	3

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10002562

Policy instance

Insurance contract or identification number	10002562
Number of Individuals Covered	61
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $19,327
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $410,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,327
Insurance broker organization code?	3

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

Policy contract number

ETB131007

Policy instance

Insurance contract or identification number	ETB131007
Number of Individuals Covered	223
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $319
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $319
Insurance broker organization code?	3

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

Policy contract number

5937695

Policy instance

Insurance contract or identification number	5937695
Number of Individuals Covered	851
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,406
Total amount of fees paid to insurance company	USD $237
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $196,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,406
Amount paid for insurance broker fees	237
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

4EL-6656-18

Policy instance

Insurance contract or identification number	4EL-6656-18
Number of Individuals Covered	288
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $513
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $513
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

34024

Policy instance

Insurance contract or identification number	34024
Number of Individuals Covered	237
Insurance policy start date	2018-04-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $32,910
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,342,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,910
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

202926

Policy instance

Insurance contract or identification number	202926
Number of Individuals Covered	311
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,599
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $6,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,430
Insurance broker organization code?	4

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

Policy contract number

97454151001

Policy instance

Insurance contract or identification number	97454151001
Number of Individuals Covered	361
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,694
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,694
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

665104

Policy instance

Insurance contract or identification number	665104
Number of Individuals Covered	10
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,920
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $183,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,920
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10002562

Policy instance

Insurance contract or identification number	10002562
Number of Individuals Covered	69
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $22,664
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $422,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,664
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

ETB131007

Policy instance

Insurance contract or identification number	ETB131007
Number of Individuals Covered	107
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $350
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $2,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $350
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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

Policy contract number

TM05937695

Policy instance

Insurance contract or identification number	TM05937695
Number of Individuals Covered	386
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $16,440
Total amount of fees paid to insurance company	USD $5,246
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $171,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,440
Amount paid for insurance broker fees	5246
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )

Policy contract number

4EL-6656-15

Policy instance

Insurance contract or identification number	4EL-6656-15
Number of Individuals Covered	246
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $849
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $849
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1071183

Policy instance

Insurance contract or identification number	1071183
Number of Individuals Covered	396
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,827
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $118,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,827
Insurance broker organization code?	3
Insurance broker name	J.S. CLARK AGENCY, INC.

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Company Name:	DEARBORN HOLDING COMPANY, LLC
Employer identification number (EIN):	811151147
NAIC Classification:	238900

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	5934294