HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 401k Plan overview

Plan Name	HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN
Plan identification number	501

HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS 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

HOLY CROSS ELECTRIC ASSOCIATION has sponsored the creation of one or more 401k plans.

Company Name:	HOLY CROSS ELECTRIC ASSOCIATION
Employer identification number (EIN):	840229176
NAIC Classification:	221100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	JOHN ROWLEY	2023-09-25
501	2021-01-01	JOHN ROWLEY	2022-10-05
501	2020-01-01	JOHN ROWLEY	2021-10-06
501	2019-01-01	JOHN ROWLEY	2020-10-13
501	2018-01-01	JOHN ROWLEY	2019-10-14
501	2017-01-01
501	2017-01-01
501	2017-01-01
501	2016-01-01
501	2015-01-01	JOHN ROWLEY
501	2014-01-01	JOHN D ROWLEY
501	2013-01-01	JOHN ROWLEY
501	2012-01-01	JOHN D ROWLEY
501	2011-01-01	TIM CHARLTON
501	2009-01-01	VICKY VELASQUEZ
501	2009-01-01			VICKY VELASQUEZ	2010-10-04
501	2009-01-01	VICKY VELASQUEZ

Plan Statistics for HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN

401k plan membership statisitcs for HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN

Measure	Date	Value
2022: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	176
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	158
Number of retired or separated participants receiving benefits	2022-01-01	17
Number of other retired or separated participants entitled to future benefits	2022-01-01	21
Total of all active and inactive participants	2022-01-01	196
2021: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	173
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	156
Number of retired or separated participants receiving benefits	2021-01-01	14
Number of other retired or separated participants entitled to future benefits	2021-01-01	6
Total of all active and inactive participants	2021-01-01	176
2020: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	176
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	151
Number of retired or separated participants receiving benefits	2020-01-01	22
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	173
2019: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	168
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	159
Number of retired or separated participants receiving benefits	2019-01-01	16
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	175
2018: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	165
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	165
Number of retired or separated participants receiving benefits	2018-01-01	3
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	168
Number of employers contributing to the scheme	2018-01-01	0
2017: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	154
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	164
Number of retired or separated participants receiving benefits	2017-01-01	1
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	165
2016: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	160
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	154
Number of retired or separated participants receiving benefits	2016-01-01	0
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	154
2015: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	160
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	154
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	154
2014: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	158
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	160
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	160
2013: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	158
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	151
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	7
Total of all active and inactive participants	2013-01-01	158
2012: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	163
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	158
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	158
2011: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	170
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	150
Number of retired or separated participants receiving benefits	2011-01-01	13
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	163
2009: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	180
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	161
Number of retired or separated participants receiving benefits	2009-01-01	16
Total of all active and inactive participants	2009-01-01	177
Total participants	2009-01-01	177

Financial Data on HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN

Measure	Date	Value
2022 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$1,537,816
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$507,856
Total income from all sources (including contributions)	2022-12-31	$5,002,669
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$5,435,380
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$5,237,031
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$5,000,180
Value of total assets at end of year	2022-12-31	$6,335,415
Value of total assets at beginning of year	2022-12-31	$5,738,166
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$198,349
Total interest from all sources	2022-12-31	$2,489
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Administrative expenses professional fees incurred	2022-12-31	$188,929
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$630,496
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$811,276
Value of other receiveables (less allowance for doubtful accounts) at end of year	2022-12-31	$690,193
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2022-12-31	$110,421
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$8,600
Administrative expenses (other) incurred	2022-12-31	$170
Total non interest bearing cash at end of year	2022-12-31	$5,118,120
Total non interest bearing cash at beginning of year	2022-12-31	$5,101,007
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-432,711
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$4,797,599
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$5,230,310
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2022-12-31	$527,102
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2022-12-31	$526,738
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2022-12-31	$526,738
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2022-12-31	$2,489
Expenses. Payments to insurance carriers foe the provision of benefits	2022-12-31	$690,292
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$3,558,408
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$4,546,739
Contract administrator fees	2022-12-31	$9,250
Liabilities. Value of benefit claims payable at end of year	2022-12-31	$1,537,816
Liabilities. Value of benefit claims payable at beginning of year	2022-12-31	$499,256
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Qualified
Accountancy firm name	2022-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2022-12-31	841509269
2021 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$507,856
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$476,292
Total income from all sources (including contributions)	2021-12-31	$5,258,044
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$4,837,806
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$4,641,902
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$5,254,999
Value of total assets at end of year	2021-12-31	$5,738,166
Value of total assets at beginning of year	2021-12-31	$5,286,364
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$195,904
Total interest from all sources	2021-12-31	$3,045
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Administrative expenses professional fees incurred	2021-12-31	$187,283
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$653,310
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$699,884
Value of other receiveables (less allowance for doubtful accounts) at end of year	2021-12-31	$110,421
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2021-12-31	$83,762
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2021-12-31	$8,600
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2021-12-31	$8,350
Administrative expenses (other) incurred	2021-12-31	$21
Total non interest bearing cash at end of year	2021-12-31	$5,101,007
Total non interest bearing cash at beginning of year	2021-12-31	$4,676,937
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$420,238
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$5,230,310
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$4,810,072
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2021-12-31	$526,738
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2021-12-31	$525,665
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2021-12-31	$525,665
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2021-12-31	$3,045
Expenses. Payments to insurance carriers foe the provision of benefits	2021-12-31	$827,012
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$3,901,805
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$3,814,890
Contract administrator fees	2021-12-31	$8,600
Liabilities. Value of benefit claims payable at end of year	2021-12-31	$499,256
Liabilities. Value of benefit claims payable at beginning of year	2021-12-31	$467,942
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Qualified
Accountancy firm name	2021-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2021-12-31	841509269
2020 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$476,292
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$492,463
Total income from all sources (including contributions)	2020-12-31	$6,013,827
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$3,919,913
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$3,731,828
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$6,000,769
Value of total assets at end of year	2020-12-31	$5,286,364
Value of total assets at beginning of year	2020-12-31	$3,208,621
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$188,085
Total interest from all sources	2020-12-31	$13,058
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Administrative expenses professional fees incurred	2020-12-31	$179,642
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$842,290
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$249,140
Value of other receiveables (less allowance for doubtful accounts) at end of year	2020-12-31	$83,762
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2020-12-31	$101,683
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2020-12-31	$8,350
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2020-12-31	$0
Administrative expenses (other) incurred	2020-12-31	$93
Total non interest bearing cash at end of year	2020-12-31	$4,676,937
Total non interest bearing cash at beginning of year	2020-12-31	$2,590,753
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$2,093,914
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$4,810,072
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$2,716,158
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2020-12-31	$525,665
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2020-12-31	$516,185
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2020-12-31	$516,185
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2020-12-31	$13,058
Expenses. Payments to insurance carriers foe the provision of benefits	2020-12-31	$913,787
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$4,909,339
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$2,818,041
Contract administrator fees	2020-12-31	$8,350
Liabilities. Value of benefit claims payable at end of year	2020-12-31	$467,942
Liabilities. Value of benefit claims payable at beginning of year	2020-12-31	$492,463
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Qualified
Accountancy firm name	2020-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2020-12-31	841509269
2019 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$492,463
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$217,075
Total income from all sources (including contributions)	2019-12-31	$5,881,426
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$4,616,068
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$4,414,754
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$5,869,835
Value of total assets at end of year	2019-12-31	$3,208,621
Value of total assets at beginning of year	2019-12-31	$1,667,875
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$201,314
Total interest from all sources	2019-12-31	$11,591
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Administrative expenses professional fees incurred	2019-12-31	$193,062
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$873,257
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$234,106
Value of other receiveables (less allowance for doubtful accounts) at end of year	2019-12-31	$101,683
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2019-12-31	$40,884
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2019-12-31	$0
Administrative expenses (other) incurred	2019-12-31	$152
Total non interest bearing cash at end of year	2019-12-31	$2,590,753
Total non interest bearing cash at beginning of year	2019-12-31	$1,117,594
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$1,265,358
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$2,716,158
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$1,450,800
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2019-12-31	$516,185
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2019-12-31	$509,397
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2019-12-31	$509,397
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2019-12-31	$11,591
Expenses. Payments to insurance carriers foe the provision of benefits	2019-12-31	$783,604
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$4,762,472
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$3,631,150
Contract administrator fees	2019-12-31	$8,100
Liabilities. Value of benefit claims payable at end of year	2019-12-31	$492,463
Liabilities. Value of benefit claims payable at beginning of year	2019-12-31	$217,075
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	No
Opinion of an independent qualified public accountant for this plan	2019-12-31	Qualified
Accountancy firm name	2019-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2019-12-31	841509269
2018 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2018 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$217,075
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$844,365
Total income from all sources (including contributions)	2018-12-31	$5,339,971
Total of all expenses incurred	2018-12-31	$4,801,949
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$4,624,352
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$5,334,872
Value of total assets at end of year	2018-12-31	$1,667,875
Value of total assets at beginning of year	2018-12-31	$1,757,143
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$177,597
Total interest from all sources	2018-12-31	$5,099
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Administrative expenses professional fees incurred	2018-12-31	$169,772
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$657,773
Income. Received or receivable in cash from other sources (including rollovers)	2018-12-31	$452,985
Value of other receiveables (less allowance for doubtful accounts) at end of year	2018-12-31	$40,884
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2018-12-31	$340,062
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2018-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2018-12-31	$13,525
Total non interest bearing cash at end of year	2018-12-31	$1,117,594
Total non interest bearing cash at beginning of year	2018-12-31	$910,881
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$538,022
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$1,450,800
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$912,778
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2018-12-31	$509,397
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2018-12-31	$506,200
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2018-12-31	$506,200
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2018-12-31	$5,099
Expenses. Payments to insurance carriers foe the provision of benefits	2018-12-31	$673,912
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Contributions received in cash from employer	2018-12-31	$4,224,114
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$3,950,440
Contract administrator fees	2018-12-31	$7,825
Liabilities. Value of benefit claims payable at end of year	2018-12-31	$217,075
Liabilities. Value of benefit claims payable at beginning of year	2018-12-31	$830,840
Did the plan have assets held for investment	2018-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	No
Opinion of an independent qualified public accountant for this plan	2018-12-31	Qualified
Accountancy firm name	2018-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2018-12-31	841509269
2017 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$844,365
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$479,901
Total income from all sources (including contributions)	2017-12-31	$5,357,785
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$5,713,415
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$5,548,667
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$5,355,200
Value of total assets at end of year	2017-12-31	$1,757,143
Value of total assets at beginning of year	2017-12-31	$1,748,309
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$164,748
Total interest from all sources	2017-12-31	$2,585
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Administrative expenses professional fees incurred	2017-12-31	$7,575
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$488,273
Income. Received or receivable in cash from other sources (including rollovers)	2017-12-31	$1,372,355
Value of other receiveables (less allowance for doubtful accounts) at end of year	2017-12-31	$340,062
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2017-12-31	$374,385
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2017-12-31	$13,525
Administrative expenses (other) incurred	2017-12-31	$8,886
Total non interest bearing cash at end of year	2017-12-31	$910,881
Total non interest bearing cash at beginning of year	2017-12-31	$869,237
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$-355,630
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$912,778
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$1,268,408
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2017-12-31	$506,200
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2017-12-31	$504,687
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2017-12-31	$504,687
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2017-12-31	$2,585
Expenses. Payments to insurance carriers foe the provision of benefits	2017-12-31	$553,142
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$3,494,572
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$4,995,525
Contract administrator fees	2017-12-31	$148,287
Liabilities. Value of benefit claims payable at end of year	2017-12-31	$830,840
Liabilities. Value of benefit claims payable at beginning of year	2017-12-31	$479,901
Did the plan have assets held for investment	2017-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	No
Opinion of an independent qualified public accountant for this plan	2017-12-31	Qualified
Accountancy firm name	2017-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2017-12-31	841509269
2016 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$479,901
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$303,677
Total income from all sources (including contributions)	2016-12-31	$4,206,676
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$4,815,710
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$4,646,880
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$4,202,283
Value of total assets at end of year	2016-12-31	$1,748,309
Value of total assets at beginning of year	2016-12-31	$2,181,119
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$168,830
Total interest from all sources	2016-12-31	$4,393
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Administrative expenses professional fees incurred	2016-12-31	$7,350
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$462,520
Income. Received or receivable in cash from other sources (including rollovers)	2016-12-31	$734,149
Value of other receiveables (less allowance for doubtful accounts) at end of year	2016-12-31	$374,385
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2016-12-31	$24,671
Total non interest bearing cash at end of year	2016-12-31	$869,237
Total non interest bearing cash at beginning of year	2016-12-31	$1,653,843
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$-609,034
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$1,268,408
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$1,877,442
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2016-12-31	$504,687
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2016-12-31	$502,605
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2016-12-31	$502,605
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2016-12-31	$4,393
Expenses. Payments to insurance carriers foe the provision of benefits	2016-12-31	$525,959
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$3,005,614
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$4,120,921
Contract administrator fees	2016-12-31	$161,480
Liabilities. Value of benefit claims payable at end of year	2016-12-31	$479,901
Liabilities. Value of benefit claims payable at beginning of year	2016-12-31	$303,677
Did the plan have assets held for investment	2016-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	No
Opinion of an independent qualified public accountant for this plan	2016-12-31	Qualified
Accountancy firm name	2016-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2016-12-31	841509269
2015 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$303,677
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$159,381
Total income from all sources (including contributions)	2015-12-31	$3,286,327
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$3,765,599
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$3,676,626
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$3,282,425
Value of total assets at end of year	2015-12-31	$2,181,119
Value of total assets at beginning of year	2015-12-31	$2,516,095
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$88,973
Total interest from all sources	2015-12-31	$3,902
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Administrative expenses professional fees incurred	2015-12-31	$7,150
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$382,058
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$82,336
Value of other receiveables (less allowance for doubtful accounts) at end of year	2015-12-31	$24,671
Total non interest bearing cash at end of year	2015-12-31	$1,653,843
Total non interest bearing cash at beginning of year	2015-12-31	$2,014,294
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-479,272
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$1,877,442
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$2,356,714
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2015-12-31	$502,605
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2015-12-31	$501,801
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2015-12-31	$501,801
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2015-12-31	$3,902
Expenses. Payments to insurance carriers foe the provision of benefits	2015-12-31	$593,128
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$2,818,031
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$3,083,498
Contract administrator fees	2015-12-31	$81,823
Liabilities. Value of benefit claims payable at end of year	2015-12-31	$303,677
Liabilities. Value of benefit claims payable at beginning of year	2015-12-31	$159,381
Did the plan have assets held for investment	2015-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	No
Opinion of an independent qualified public accountant for this plan	2015-12-31	Unqualified
Accountancy firm name	2015-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2015-12-31	841509269
2014 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$159,381
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$204,359
Total income from all sources (including contributions)	2014-12-31	$3,179,172
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$3,286,345
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$3,213,615
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$3,174,396
Value of total assets at end of year	2014-12-31	$2,516,095
Value of total assets at beginning of year	2014-12-31	$2,668,246
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$72,730
Total interest from all sources	2014-12-31	$4,776
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Administrative expenses professional fees incurred	2014-12-31	$6,950
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$375,083
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$35,835
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2014-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2014-12-31	$3,250
Total non interest bearing cash at end of year	2014-12-31	$2,014,294
Total non interest bearing cash at beginning of year	2014-12-31	$2,166,683
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$-107,173
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$2,356,714
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$2,463,887
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2014-12-31	$501,801
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2014-12-31	$501,563
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2014-12-31	$501,563
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2014-12-31	$4,776
Expenses. Payments to insurance carriers foe the provision of benefits	2014-12-31	$573,238
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$2,763,478
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$2,640,377
Contract administrator fees	2014-12-31	$65,780
Liabilities. Value of benefit claims payable at end of year	2014-12-31	$159,381
Liabilities. Value of benefit claims payable at beginning of year	2014-12-31	$201,109
Did the plan have assets held for investment	2014-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	No
Opinion of an independent qualified public accountant for this plan	2014-12-31	Unqualified
Accountancy firm name	2014-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2014-12-31	841509269
2013 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$204,359
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$411,503
Total income from all sources (including contributions)	2013-12-31	$3,473,551
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$3,397,252
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$3,340,391
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$3,468,743
Value of total assets at end of year	2013-12-31	$2,668,246
Value of total assets at beginning of year	2013-12-31	$2,799,091
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$56,861
Total interest from all sources	2013-12-31	$4,808
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Administrative expenses professional fees incurred	2013-12-31	$6,750
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$386,187
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$355,424
Value of other receiveables (less allowance for doubtful accounts) at end of year	2013-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2013-12-31	$23,607
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2013-12-31	$3,250
Total non interest bearing cash at end of year	2013-12-31	$2,166,683
Total non interest bearing cash at beginning of year	2013-12-31	$2,519,879
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$76,299
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$2,463,887
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$2,387,588
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2013-12-31	$501,563
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2013-12-31	$255,605
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2013-12-31	$255,605
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2013-12-31	$4,808
Expenses. Payments to insurance carriers foe the provision of benefits	2013-12-31	$597,373
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$2,727,132
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$2,743,018
Contract administrator fees	2013-12-31	$50,111
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2013-12-31	No
Liabilities. Value of benefit claims payable at end of year	2013-12-31	$201,109
Liabilities. Value of benefit claims payable at beginning of year	2013-12-31	$411,503
Did the plan have assets held for investment	2013-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	No
Opinion of an independent qualified public accountant for this plan	2013-12-31	Unqualified
Accountancy firm name	2013-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2013-12-31	841509269
2012 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$411,503
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$168,645
Total income from all sources (including contributions)	2012-12-31	$3,105,832
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$2,770,849
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$2,715,654
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$3,100,597
Value of total assets at end of year	2012-12-31	$2,799,091
Value of total assets at beginning of year	2012-12-31	$2,221,250
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$55,195
Total interest from all sources	2012-12-31	$5,235
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Administrative expenses professional fees incurred	2012-12-31	$6,750
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$395,010
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$21,412
Value of other receiveables (less allowance for doubtful accounts) at end of year	2012-12-31	$23,607
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2012-12-31	$44,174
Total non interest bearing cash at end of year	2012-12-31	$2,519,879
Total non interest bearing cash at beginning of year	2012-12-31	$1,919,635
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$334,983
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$2,387,588
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$2,052,605
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$255,605
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$257,441
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$257,441
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2012-12-31	$5,235
Expenses. Payments to insurance carriers foe the provision of benefits	2012-12-31	$552,233
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$2,684,175
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$2,163,421
Contract administrator fees	2012-12-31	$48,445
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2012-12-31	No
Liabilities. Value of benefit claims payable at end of year	2012-12-31	$411,503
Liabilities. Value of benefit claims payable at beginning of year	2012-12-31	$168,645
Did the plan have assets held for investment	2012-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	No
Opinion of an independent qualified public accountant for this plan	2012-12-31	Unqualified
Accountancy firm name	2012-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2012-12-31	841509269
2011 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$168,645
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$246,125
Total income from all sources (including contributions)	2011-12-31	$3,391,738
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$3,173,085
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$3,114,916
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$3,381,911
Value of total assets at end of year	2011-12-31	$2,221,250
Value of total assets at beginning of year	2011-12-31	$2,080,077
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$58,169
Total interest from all sources	2011-12-31	$9,827
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Administrative expenses professional fees incurred	2011-12-31	$6,650
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$448,430
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$173,500
Value of other receiveables (less allowance for doubtful accounts) at end of year	2011-12-31	$44,174
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2011-12-31	$127,043
Total non interest bearing cash at end of year	2011-12-31	$1,919,635
Total non interest bearing cash at beginning of year	2011-12-31	$1,447,100
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$218,653
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$2,052,605
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$1,833,952
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$257,441
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-12-31	$505,934
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-12-31	$505,934
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2011-12-31	$9,827
Expenses. Payments to insurance carriers foe the provision of benefits	2011-12-31	$502,433
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$2,759,981
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$2,612,483
Contract administrator fees	2011-12-31	$51,519
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2011-12-31	No
Liabilities. Value of benefit claims payable at end of year	2011-12-31	$168,645
Liabilities. Value of benefit claims payable at beginning of year	2011-12-31	$246,125
Did the plan have assets held for investment	2011-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	No
Opinion of an independent qualified public accountant for this plan	2011-12-31	Unqualified
Accountancy firm name	2011-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2011-12-31	841509269
2010 : HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2010 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$246,125
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$174,548
Total income from all sources (including contributions)	2010-12-31	$3,526,265
Total of all expenses incurred	2010-12-31	$2,995,508
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$2,929,028
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$3,514,177
Value of total assets at end of year	2010-12-31	$2,080,077
Value of total assets at beginning of year	2010-12-31	$1,477,743
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$66,480
Total interest from all sources	2010-12-31	$12,088
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Administrative expenses professional fees incurred	2010-12-31	$6,650
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$503,556
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$179,795
Value of other receiveables (less allowance for doubtful accounts) at end of year	2010-12-31	$127,043
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2010-12-31	$198,260
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2010-12-31	$3,650
Administrative expenses (other) incurred	2010-12-31	$372
Total non interest bearing cash at end of year	2010-12-31	$1,447,100
Total non interest bearing cash at beginning of year	2010-12-31	$1,274,135
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$530,757
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$1,833,952
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$1,303,195
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2010-12-31	$505,934
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2010-12-31	$5,348
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2010-12-31	$5,348
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2010-12-31	$12,088
Expenses. Payments to insurance carriers foe the provision of benefits	2010-12-31	$441,888
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$2,830,826
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$2,487,140
Contract administrator fees	2010-12-31	$59,458
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2010-12-31	No
Liabilities. Value of benefit claims payable at end of year	2010-12-31	$246,125
Liabilities. Value of benefit claims payable at beginning of year	2010-12-31	$170,898
Did the plan have assets held for investment	2010-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	No
Opinion of an independent qualified public accountant for this plan	2010-12-31	Unqualified
Accountancy firm name	2010-12-31	MCMAHAN AND ASSOCIATES, LLC
Accountancy firm EIN	2010-12-31	841509269

Form 5500 Responses for HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN

2022: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	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 - Trust	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	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 - Trust	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	Yes
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: HOLY CROSS ELECTRIC ASSOCIATION MEDICAL AND DENTAL BENEFITS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30044133
Policy instance	3
Insurance contract or identification number 30044133 Number of Individuals Covered 136 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,248 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $24,618 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,248 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract number	HC1
Policy instance	1
Insurance contract or identification number HC1 Number of Individuals Covered 158 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,421 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HUB1002AA
Policy instance	2
Insurance contract or identification number HUB1002AA Number of Individuals Covered 172 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,964 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	024893
Policy instance	10
Insurance contract or identification number 024893 Number of Individuals Covered 55 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $2,740 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,443 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,740 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	16-015556-000
Policy instance	4
Insurance contract or identification number 16-015556-000 Number of Individuals Covered 338 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $24,008 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $632,338 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 24008 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0BNX2
Policy instance	5
Insurance contract or identification number GLTD0BNX2 Number of Individuals Covered 163 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $9,632 Total amount of fees paid to insurance company USD $4,912 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $64,215 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,632 Amount paid for insurance broker fees 4912 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0BNX2
Policy instance	6
Insurance contract or identification number GLUG0BNX2 Number of Individuals Covered 163 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $11,257 Total amount of fees paid to insurance company USD $5,719 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $75,046 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,257 Amount paid for insurance broker fees 5719 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract number	GMDC0BNX2
Policy instance	7
Insurance contract or identification number GMDC0BNX2 Number of Individuals Covered 37 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $790 Total amount of fees paid to insurance company USD $389 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,269 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $790 Amount paid for insurance broker fees 389 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0BNX2
Policy instance	8
Insurance contract or identification number GUC0BNX2 Number of Individuals Covered 31 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $2,220 Total amount of fees paid to insurance company USD $1,027 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,802 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,220 Amount paid for insurance broker fees 1027 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0BNX2
Policy instance	9
Insurance contract or identification number GVTL0BNX2 Number of Individuals Covered 43 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $4,841 Total amount of fees paid to insurance company USD $2,398 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $32,276 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,841 Amount paid for insurance broker fees 2398 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HUB1002AA
Policy instance	2
Insurance contract or identification number HUB1002AA Number of Individuals Covered 174 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $106 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,331 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $106 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract number	HC1
Policy instance	1
Insurance contract or identification number HC1 Number of Individuals Covered 162 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,549 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30044133
Policy instance	3
Insurance contract or identification number 30044133 Number of Individuals Covered 137 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,408 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,873 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $768 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number	407557-A
Policy instance	4
Insurance contract or identification number 407557-A Number of Individuals Covered 170 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $672,849 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0BNX2
Policy instance	5
Insurance contract or identification number GLTD0BNX2 Number of Individuals Covered 164 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $9,741 Total amount of fees paid to insurance company USD $3,663 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $64,937 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,741 Amount paid for insurance broker fees 3663 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0BNX2
Policy instance	6
Insurance contract or identification number GLUG0BNX2 Number of Individuals Covered 165 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $11,342 Total amount of fees paid to insurance company USD $4,283 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $75,615 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,342 Amount paid for insurance broker fees 4283 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract number	GMDC0BNX2
Policy instance	7
Insurance contract or identification number GMDC0BNX2 Number of Individuals Covered 34 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $834 Total amount of fees paid to insurance company USD $421 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,560 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $834 Amount paid for insurance broker fees 421 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0BNX2
Policy instance	8
Insurance contract or identification number GUC0BNX2 Number of Individuals Covered 29 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $2,063 Total amount of fees paid to insurance company USD $550 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,756 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,063 Amount paid for insurance broker fees 550 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0BNX2
Policy instance	9
Insurance contract or identification number GVTL0BNX2 Number of Individuals Covered 43 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $5,138 Total amount of fees paid to insurance company USD $2,075 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $34,254 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,138 Amount paid for insurance broker fees 2075 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract number	HOLY CROSS EAP
Policy instance	1
Insurance contract or identification number HOLY CROSS EAP Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,475 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HUB1002AA
Policy instance	2
Insurance contract or identification number HUB1002AA Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $97 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,369 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $97 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30044133
Policy instance	3
Insurance contract or identification number 30044133 Number of Individuals Covered 136 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,018 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,319 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,018 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD0BNX2
Policy instance	5
Insurance contract or identification number GLTD0BNX2 Number of Individuals Covered 166 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $9,444 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $62,959 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,444 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	16-014849-00
Policy instance	4
Insurance contract or identification number 16-014849-00 Number of Individuals Covered 176 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $766,650 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG0BNX2
Policy instance	6
Insurance contract or identification number GLUG0BNX2 Number of Individuals Covered 166 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $11,035 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $73,565 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,035 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract number	GMDC0BNX2
Policy instance	7
Insurance contract or identification number GMDC0BNX2 Number of Individuals Covered 35 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $875 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,834 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $875 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GVTL0BNX2
Policy instance	9
Insurance contract or identification number GVTL0BNX2 Number of Individuals Covered 42 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $4,243 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $28,284 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,243 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GUC0BNX2
Policy instance	8
Insurance contract or identification number GUC0BNX2 Number of Individuals Covered 29 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,613 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,755 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,613 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
BERKSHIRE HATHAWAY SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22276 )
Policy contract number	47-MSL-00016602
Policy instance	5
Insurance contract or identification number 47-MSL-00016602 Number of Individuals Covered 174 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $644,350 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30044133
Policy instance	4
Insurance contract or identification number 30044133 Number of Individuals Covered 131 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $1,098 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,477 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,098 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HUB1002AA
Policy instance	3
Insurance contract or identification number HUB1002AA Number of Individuals Covered 175 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $115 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,074 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $115 Amount paid for insurance broker fees 0 Additional information about fees paid to insurance broker COMMISSIONS Insurance broker organization code? 3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract number	HOLY CROSS EAP
Policy instance	2
Insurance contract or identification number HOLY CROSS EAP Number of Individuals Covered 148 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,232 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	195613
Policy instance	1
Insurance contract or identification number 195613 Insurance policy start date 2019-03-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $22,300 Total amount of fees paid to insurance company USD $1,014 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $140,499 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $22,300 Amount paid for insurance broker fees 1014 Additional information about fees paid to insurance broker COMMISSIONS AND FEES Insurance broker organization code? 3
BERKSHIRE HATHAWAY SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22276 )
Policy contract number	ERLL14100801002
Policy instance	5
Insurance contract or identification number ERLL14100801002 Number of Individuals Covered 165 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Welfare Benefit Premiums Paid to Carrier USD $501,337 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30044133
Policy instance	4
Insurance contract or identification number 30044133 Number of Individuals Covered 120 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,099 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $20,022 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,099 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	HUB1002AA
Policy instance	3
Insurance contract or identification number HUB1002AA Number of Individuals Covered 165 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $1,438 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Other welfare benefits provided VOLUNTARY BENEFITS Welfare Benefit Premiums Paid to Carrier USD $10,723 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1,438 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract number	HOLY CROSS EAP
Policy instance	2
Insurance contract or identification number HOLY CROSS EAP Number of Individuals Covered 153 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $4,246 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	195613
Policy instance	1
Insurance contract or identification number 195613 Number of Individuals Covered 165 Insurance policy start date 2017-03-01 Insurance policy end date 2018-02-28 Total amount of commissions paid to insurance broker USD $27,240 Total amount of fees paid to insurance company USD $9,663 Life Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $193,685 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $27,240 Amount paid for insurance broker fees 9663 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30044133
Policy instance	1
Insurance contract or identification number 30044133 Number of Individuals Covered 122 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $1,146 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,862 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,146 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	00
Policy instance	2
Insurance contract or identification number 00 Number of Individuals Covered 161 Insurance policy start date 2016-03-01 Insurance policy end date 2017-02-28 Total amount of commissions paid to insurance broker USD $23,872 Total amount of fees paid to insurance company USD $181 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $153,509 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $23,872 Amount paid for insurance broker fees 181 Additional information about fees paid to insurance broker INDIRECT COMPENSATION Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	3
Insurance contract or identification number 00 Number of Individuals Covered 164 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $3,465 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,483 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $3,465 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	2
Insurance contract or identification number 00 Number of Individuals Covered 157 Insurance policy start date 2016-03-01 Insurance policy end date 2017-02-28 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract number	HC1
Policy instance	4
Insurance contract or identification number HC1 Number of Individuals Covered 152 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,246 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	00
Policy instance	4
Insurance contract or identification number 00 Number of Individuals Covered 152 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	195613
Policy instance	3
Insurance contract or identification number 195613 Number of Individuals Covered 154 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $31,915 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $150,034 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $31,915 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30044133
Policy instance	2
Insurance contract or identification number 30044133 Number of Individuals Covered 111 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $1,049 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,021 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,049 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )
Policy contract number	ERLL14100801002
Policy instance	1
Insurance contract or identification number ERLL14100801002 Number of Individuals Covered 154 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $68,786 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $458,574 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $68,786 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )
Policy contract number	195613
Policy instance	4
Insurance contract or identification number 195613 Number of Individuals Covered 154 Insurance policy start date 2014-03-01 Insurance policy end date 2015-02-28 Total amount of commissions paid to insurance broker USD $738 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,469 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $738 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number	30044133
Policy instance	1
Insurance contract or identification number 30044133 Number of Individuals Covered 97 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $950 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,497 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $950 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )
Policy contract number	ERLL14100801
Policy instance	2
Insurance contract or identification number ERLL14100801 Number of Individuals Covered 160 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $66,907 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $446,045 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $66,907 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	195613
Policy instance	3
Insurance contract or identification number 195613 Number of Individuals Covered 160 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $19,697 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $104,603 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $19,697 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )
Policy contract number	195613
Policy instance	4
Insurance contract or identification number 195613 Number of Individuals Covered 160 Insurance policy start date 2013-03-01 Insurance policy end date 2014-02-28 Total amount of commissions paid to insurance broker USD $433 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,300 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $433 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	212717
Policy instance	1
Insurance contract or identification number 212717 Number of Individuals Covered 153 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $3,460 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,065 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,460 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCS., INC.
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number	67554-7
Policy instance	2
Insurance contract or identification number 67554-7 Number of Individuals Covered 431 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $71,016 Total amount of fees paid to insurance company USD $4,719 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $473,440 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $71,016 Insurance broker organization code? 3 Amount paid for insurance broker fees 4719 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker name HUB INTERNATIONAL INS. SVCS., INC.
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	195613
Policy instance	3
Insurance contract or identification number 195613 Number of Individuals Covered 645 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $16,336 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM. ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $101,289 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,336 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCS., INC.
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number	67554-7
Policy instance	2
Insurance contract or identification number 67554-7 Number of Individuals Covered 448 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $64,267 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $428,445 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $64,267 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	212717
Policy instance	1
Insurance contract or identification number 212717 Number of Individuals Covered 153 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $22,176 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $150,229 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,176 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL INS. SVCES., INC.
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	212717
Policy instance	1
Insurance contract or identification number 212717 Number of Individuals Covered 163 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $21,276 Total amount of fees paid to insurance company USD $9,251 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $151,557 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract number	5014-20110-Q
Policy instance	2
Insurance contract or identification number 5014-20110-Q Number of Individuals Covered 163 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $57,007 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $380,044 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract number	5014-20100-Q
Policy instance	1
Insurance contract or identification number 5014-20100-Q Number of Individuals Covered 173 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $47,855 Welfare Benefit Premiums Paid to Carrier USD $319,033 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $47,855 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL SOUTHWEST
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	212717
Policy instance	5
Insurance contract or identification number 212717 Number of Individuals Covered 156 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $8,114 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $54,091 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,114 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL SOUTHWEST
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	212717
Policy instance	4
Insurance contract or identification number 212717 Number of Individuals Covered 160 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $6,770 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $45,136 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,770 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL SOUTHWEST
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLUG087Y8
Policy instance	3
Insurance contract or identification number GLUG087Y8 Number of Individuals Covered 163 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,155 Life Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $9,622 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,155 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL SOUTHWEST
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number	GLTD087Y8
Policy instance	2
Insurance contract or identification number GLTD087Y8 Number of Individuals Covered 163 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $1,162 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $12,909 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,162 Insurance broker organization code? 3 Insurance broker name HUB INTERNATIONAL SOUTHWEST

Potentially related plans

• HOLY CROSS HOSPITAL RETIREMENT SAVINGS PLAN [EIN = 850289839]
• HOLY CROSS HOSPITAL EMPLOYEE BENEFIT PLAN [EIN = 850289839]
• HOLY CROSS RETIREMENT PLAN FOR NONEXEMPT EMPLOYEES [EIN = 042103558]
• HOLY CROSS ANESTHESIOLOGY ASSOCIATES, P.A. PROFIT SHARING [EIN = 521407594]
• HOLY CROSS FAMILY PRACTICE ASSOCIATION 401(K) PROFIT SHARING PLAN & TRUST [EIN = 742524427]
• HOLY CROSS RETIREMENT PLAN [EIN = 510065692]
• HOLY CROSS APOTHECARY, INC. PROFIT SHARING PLAN [EIN = 954074033]
• HOLY CROSS ANGLICAN CHURCH 403(B) RETIREMENT PLAN [EIN = 203945971]
• HOLY CROSS COLLEGE SECTION 403(B) DEFINED CONTRIBUTION RETIREMENT PLAN [EIN = 351148835]
• HOLY CROSS VILLAGE 401(K) RETIREMENT PLAN [EIN = 352084623]
• HOLY CROSS FLEX PLAN [EIN = 042103558]
• HOLY CROSS HOSPITAL WELFARE BENEFIT PLAN [EIN = 362170133]
• HOLY CROSS OBGYN 401(K) P/S PLAN [EIN = 823655101]
• HOLY CROSS EARLY LEARNING CENT 401 K PROFIT SHARING PLAN TRUST [EIN = 824070547]
• HOLY CROSS OF SAN ANTONIO 403(B) PLAN [EIN = 741291746]
• HOLY CROSS PRESCHOOL 401(K) PROFIT SHARING PLAN & TRUST [EIN = 953338503]
• HOLY CROSS SERVICES [EIN = 381368326]
• HOLY CROSS CUSTOM BUILDERS 401(K) PLAN [EIN = 454634236]
• HOLY CROSS OBGYN CASH BALANCE PLAN [EIN = 823655101]