401k Plan data: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN plan

COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN
Plan identification number	505

COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

COLORADO RIVER INDIAN TRIBES has sponsored the creation of one or more 401k plans.

Company Name: COLORADO RIVER INDIAN TRIBES

Employer identification number (EIN): 860092226

NAIC Classification: 921000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2022-09-01 AMELIA FLORES 2024-02-20
505 2021-09-01 AMELIA FLORES 2023-03-06
505 2020-09-01
505 2019-09-01
505 2018-09-01
505 2017-09-01
505 2016-09-01 DENNIS PATCH
505 2015-09-01 DENNIS PATCH
505 2014-09-01 DENNIS PATCH
505 2013-09-01 DENNIS PATCH
505 2012-09-01 DENNIS PATCH
505 2011-09-01 DENNIS PATCH

Plan Statistics for COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN

401k plan membership statisitcs for COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN

Measure Date Value
2022: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-09-01 758
Total number of active participants reported on line 7a of the Form 5500 2022-09-01 783
Number of retired or separated participants receiving benefits 2022-09-01 0
Number of other retired or separated participants entitled to future benefits 2022-09-01 0
Total of all active and inactive participants 2022-09-01 783
Number of employers contributing to the scheme 2022-09-01 0
2021: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-09-01 722
Total number of active participants reported on line 7a of the Form 5500 2021-09-01 761
Number of retired or separated participants receiving benefits 2021-09-01 0
Number of other retired or separated participants entitled to future benefits 2021-09-01 0
Total of all active and inactive participants 2021-09-01 761
Number of employers contributing to the scheme 2021-09-01 0
2020: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-09-01 819
Total number of active participants reported on line 7a of the Form 5500 2020-09-01 719
Number of retired or separated participants receiving benefits 2020-09-01 3
Number of other retired or separated participants entitled to future benefits 2020-09-01 0
Total of all active and inactive participants 2020-09-01 722
2019: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-09-01 691
Total number of active participants reported on line 7a of the Form 5500 2019-09-01 818
Number of retired or separated participants receiving benefits 2019-09-01 1
Number of other retired or separated participants entitled to future benefits 2019-09-01 0
Total of all active and inactive participants 2019-09-01 819
2018: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-09-01 668
Total number of active participants reported on line 7a of the Form 5500 2018-09-01 690
Number of retired or separated participants receiving benefits 2018-09-01 1
Number of other retired or separated participants entitled to future benefits 2018-09-01 0
Total of all active and inactive participants 2018-09-01 691
2017: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-09-01 442
Total number of active participants reported on line 7a of the Form 5500 2017-09-01 667
Number of retired or separated participants receiving benefits 2017-09-01 1
Number of other retired or separated participants entitled to future benefits 2017-09-01 0
Total of all active and inactive participants 2017-09-01 668
2016: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-09-01 707
Total number of active participants reported on line 7a of the Form 5500 2016-09-01 442
Number of retired or separated participants receiving benefits 2016-09-01 0
Number of other retired or separated participants entitled to future benefits 2016-09-01 0
Total of all active and inactive participants 2016-09-01 442
2015: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-09-01 817
Total number of active participants reported on line 7a of the Form 5500 2015-09-01 705
Number of retired or separated participants receiving benefits 2015-09-01 2
Number of other retired or separated participants entitled to future benefits 2015-09-01 0
Total of all active and inactive participants 2015-09-01 707
2014: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-09-01 740
Total number of active participants reported on line 7a of the Form 5500 2014-09-01 793
Number of retired or separated participants receiving benefits 2014-09-01 24
Number of other retired or separated participants entitled to future benefits 2014-09-01 0
Total of all active and inactive participants 2014-09-01 817
2013: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-09-01 639
Total number of active participants reported on line 7a of the Form 5500 2013-09-01 737
Number of retired or separated participants receiving benefits 2013-09-01 3
Number of other retired or separated participants entitled to future benefits 2013-09-01 0
Total of all active and inactive participants 2013-09-01 740
2012: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-09-01 585
Total number of active participants reported on line 7a of the Form 5500 2012-09-01 637
Number of retired or separated participants receiving benefits 2012-09-01 2
Number of other retired or separated participants entitled to future benefits 2012-09-01 0
Total of all active and inactive participants 2012-09-01 639
2011: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-09-01 589
Total number of active participants reported on line 7a of the Form 5500 2011-09-01 583
Number of retired or separated participants receiving benefits 2011-09-01 2
Number of other retired or separated participants entitled to future benefits 2011-09-01 0
Total of all active and inactive participants 2011-09-01 585

Measure	Date	Value
2022: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-09-01	758
Total number of active participants reported on line 7a of the Form 5500	2022-09-01	783
Number of retired or separated participants receiving benefits	2022-09-01	0
Number of other retired or separated participants entitled to future benefits	2022-09-01	0
Total of all active and inactive participants	2022-09-01	783
Number of employers contributing to the scheme	2022-09-01	0
2021: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-09-01	722
Total number of active participants reported on line 7a of the Form 5500	2021-09-01	761
Number of retired or separated participants receiving benefits	2021-09-01	0
Number of other retired or separated participants entitled to future benefits	2021-09-01	0
Total of all active and inactive participants	2021-09-01	761
Number of employers contributing to the scheme	2021-09-01	0
2020: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-09-01	819
Total number of active participants reported on line 7a of the Form 5500	2020-09-01	719
Number of retired or separated participants receiving benefits	2020-09-01	3
Number of other retired or separated participants entitled to future benefits	2020-09-01	0
Total of all active and inactive participants	2020-09-01	722
2019: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-09-01	691
Total number of active participants reported on line 7a of the Form 5500	2019-09-01	818
Number of retired or separated participants receiving benefits	2019-09-01	1
Number of other retired or separated participants entitled to future benefits	2019-09-01	0
Total of all active and inactive participants	2019-09-01	819
2018: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-09-01	668
Total number of active participants reported on line 7a of the Form 5500	2018-09-01	690
Number of retired or separated participants receiving benefits	2018-09-01	1
Number of other retired or separated participants entitled to future benefits	2018-09-01	0
Total of all active and inactive participants	2018-09-01	691
2017: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-09-01	442
Total number of active participants reported on line 7a of the Form 5500	2017-09-01	667
Number of retired or separated participants receiving benefits	2017-09-01	1
Number of other retired or separated participants entitled to future benefits	2017-09-01	0
Total of all active and inactive participants	2017-09-01	668
2016: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-09-01	707
Total number of active participants reported on line 7a of the Form 5500	2016-09-01	442
Number of retired or separated participants receiving benefits	2016-09-01	0
Number of other retired or separated participants entitled to future benefits	2016-09-01	0
Total of all active and inactive participants	2016-09-01	442
2015: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-09-01	817
Total number of active participants reported on line 7a of the Form 5500	2015-09-01	705
Number of retired or separated participants receiving benefits	2015-09-01	2
Number of other retired or separated participants entitled to future benefits	2015-09-01	0
Total of all active and inactive participants	2015-09-01	707
2014: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-09-01	740
Total number of active participants reported on line 7a of the Form 5500	2014-09-01	793
Number of retired or separated participants receiving benefits	2014-09-01	24
Number of other retired or separated participants entitled to future benefits	2014-09-01	0
Total of all active and inactive participants	2014-09-01	817
2013: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-09-01	639
Total number of active participants reported on line 7a of the Form 5500	2013-09-01	737
Number of retired or separated participants receiving benefits	2013-09-01	3
Number of other retired or separated participants entitled to future benefits	2013-09-01	0
Total of all active and inactive participants	2013-09-01	740
2012: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-09-01	585
Total number of active participants reported on line 7a of the Form 5500	2012-09-01	637
Number of retired or separated participants receiving benefits	2012-09-01	2
Number of other retired or separated participants entitled to future benefits	2012-09-01	0
Total of all active and inactive participants	2012-09-01	639
2011: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-09-01	589
Total number of active participants reported on line 7a of the Form 5500	2011-09-01	583
Number of retired or separated participants receiving benefits	2011-09-01	2
Number of other retired or separated participants entitled to future benefits	2011-09-01	0
Total of all active and inactive participants	2011-09-01	585

Form 5500 Responses for COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN

2022: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-09-01	Type of plan entity	Single employer plan
2022-09-01	Plan funding arrangement – Insurance	Yes
2022-09-01	Plan benefit arrangement – Insurance	Yes
2021: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-09-01	Type of plan entity	Single employer plan
2021-09-01	Plan funding arrangement – Insurance	Yes
2021-09-01	Plan benefit arrangement – Insurance	Yes
2020: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-09-01	Type of plan entity	Single employer plan
2020-09-01	Submission has been amended	No
2020-09-01	This submission is the final filing	No
2020-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-09-01	Plan is a collectively bargained plan	No
2020-09-01	Plan funding arrangement – Insurance	Yes
2020-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-09-01	Plan benefit arrangement – Insurance	Yes
2020-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-09-01	Type of plan entity	Single employer plan
2019-09-01	Submission has been amended	No
2019-09-01	This submission is the final filing	No
2019-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-09-01	Plan is a collectively bargained plan	No
2019-09-01	Plan funding arrangement – Insurance	Yes
2019-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-09-01	Plan benefit arrangement – Insurance	Yes
2019-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-09-01	Type of plan entity	Single employer plan
2018-09-01	Submission has been amended	No
2018-09-01	This submission is the final filing	No
2018-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-09-01	Plan is a collectively bargained plan	No
2018-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-09-01	Plan benefit arrangement – Insurance	Yes
2018-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-09-01	Type of plan entity	Single employer plan
2017-09-01	Submission has been amended	No
2017-09-01	This submission is the final filing	No
2017-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-09-01	Plan is a collectively bargained plan	No
2017-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-09-01	Plan benefit arrangement – Insurance	Yes
2017-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-09-01	Type of plan entity	Single employer plan
2016-09-01	Submission has been amended	No
2016-09-01	This submission is the final filing	No
2016-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-09-01	Plan is a collectively bargained plan	No
2016-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-09-01	Plan benefit arrangement – Insurance	Yes
2016-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-09-01	Type of plan entity	Single employer plan
2015-09-01	Submission has been amended	No
2015-09-01	This submission is the final filing	No
2015-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-09-01	Plan is a collectively bargained plan	No
2015-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-09-01	Plan benefit arrangement – Insurance	Yes
2015-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-09-01	Type of plan entity	Single employer plan
2014-09-01	Submission has been amended	No
2014-09-01	This submission is the final filing	No
2014-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-09-01	Plan is a collectively bargained plan	No
2014-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-09-01	Plan benefit arrangement – Insurance	Yes
2014-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-09-01	Type of plan entity	Single employer plan
2013-09-01	Submission has been amended	No
2013-09-01	This submission is the final filing	No
2013-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-09-01	Plan is a collectively bargained plan	No
2013-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-09-01	Plan benefit arrangement – Insurance	Yes
2013-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-09-01	Type of plan entity	Single employer plan
2012-09-01	Submission has been amended	No
2012-09-01	This submission is the final filing	No
2012-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-09-01	Plan is a collectively bargained plan	No
2012-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-09-01	Plan benefit arrangement – Insurance	Yes
2012-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: COLORADO RIVER INDIAN TRIBES AND AFFILIATES GROUP WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-09-01	Type of plan entity	Single employer plan
2011-09-01	Submission has been amended	Yes
2011-09-01	This submission is the final filing	No
2011-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-09-01	Plan is a collectively bargained plan	No
2011-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-09-01	Plan benefit arrangement – Insurance	Yes
2011-09-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

13460

Policy instance

Insurance contract or identification number	13460
Number of Individuals Covered	415
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $4,694
Total amount of fees paid to insurance company	USD $4,052
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
Welfare Benefit Premiums Paid to Carrier	USD $43,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $4,694
Amount paid for insurance broker fees	2879
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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

Policy contract number

01-018273-00

Policy instance

Insurance contract or identification number	01-018273-00
Number of Individuals Covered	1151
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $80,213
Total amount of fees paid to insurance company	USD $15,597
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
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $337,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67,411
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	GROUP VOLUME BONUS

JORGENSEN BROOKS GROUP (National Association of Insurance Commissioners NAIC id number: 62142 )

Policy contract number

Policy instance

Insurance contract or identification number	00
Number of Individuals Covered	498
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
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 $5,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

891882G

Policy instance

Insurance contract or identification number	891882G
Number of Individuals Covered	10
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $932
Total amount of fees paid to insurance company	USD $111
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 $6,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $932
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

932866

Policy instance

Insurance contract or identification number	932866
Number of Individuals Covered	783
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $36,051
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $341,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,051
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

042531_042532

Policy instance

Insurance contract or identification number	042531_042532
Number of Individuals Covered	964
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $164,428
Total amount of fees paid to insurance company	USD $2,250
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,859,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $164,428
Amount paid for insurance broker fees	2250
Additional information about fees paid to insurance broker	SPECIAL INCENTIVE, DENTAL BONUS
Insurance broker organization code?	3

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

Policy contract number

169611

Policy instance

Insurance contract or identification number	169611
Number of Individuals Covered	940
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $7,866
Total amount of fees paid to insurance company	USD $3,899
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $189,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,866
Amount paid for insurance broker fees	3899
Additional information about fees paid to insurance broker	2021 PINNACLE DENTAL AND VISION NEW BUSINESS INCENTIVE RISK
Insurance broker organization code?	3

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

Policy contract number

932866

Policy instance

Insurance contract or identification number	932866
Number of Individuals Covered	761
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $35,258
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $336,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,143
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

891882G

Policy instance

Insurance contract or identification number	891882G
Number of Individuals Covered	10
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $988
Total amount of fees paid to insurance company	USD $0
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 $6,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $988
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

JORGENSEN BROOKS GROUP (National Association of Insurance Commissioners NAIC id number: 62142 )

Policy contract number

Policy instance

Insurance contract or identification number	00
Number of Individuals Covered	572
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
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 $6,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16058 )

Policy contract number

169611BH

Policy instance

Insurance contract or identification number	169611BH
Number of Individuals Covered	902
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $178,656
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,259,823
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	178656
Additional information about fees paid to insurance broker	2021 Q3 BANNER HEALTH JOINT VENTURE INCENTIVE RISK, DIRECT COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

1236800

Policy instance

Insurance contract or identification number	1236800
Number of Individuals Covered	1159
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $104,816
Total amount of fees paid to insurance company	USD $0
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
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $314,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,168
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

30041741

Policy instance

Insurance contract or identification number	30041741
Number of Individuals Covered	399
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $6,140
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 $57,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,140
Insurance broker organization code?	3

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

Policy contract number

12368000

Policy instance

Insurance contract or identification number	12368000
Number of Individuals Covered	1001
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $84,221
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	ACCIDENT AND CRITICAL ILLNESS
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 $158,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,221
Insurance broker organization code?	3

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

Policy contract number

891882G

Policy instance

Insurance contract or identification number	891882G
Number of Individuals Covered	16
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $1,668
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 & 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 $11,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,668
Insurance broker organization code?	3

JORGENSEN BROOKS GROUP (National Association of Insurance Commissioners NAIC id number: 62142 )

Policy contract number

N/A

Policy instance

Insurance contract or identification number	N/A
Number of Individuals Covered	250
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
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 $2,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

018875/019007

Policy instance

Insurance contract or identification number	018875/019007
Number of Individuals Covered	486
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $168,843
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	Yes
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 $6,261,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $168,843
Insurance broker organization code?	3

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

Policy contract number

932866

Policy instance

Insurance contract or identification number	932866
Number of Individuals Covered	719
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $31,714
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $337,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,714
Insurance broker organization code?	3

JORGENSEN BROOKS GROUP (National Association of Insurance Commissioners NAIC id number: 62142 )

Policy contract number

N/A

Policy instance

Insurance contract or identification number	N/A
Number of Individuals Covered	572
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
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 $6,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

018875/019007

Policy instance

Insurance contract or identification number	018875/019007
Number of Individuals Covered	611
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $182,622
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	Yes
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 $7,019,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $182,622
Insurance broker organization code?	3

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

Policy contract number

22886

Policy instance

Insurance contract or identification number	22886
Number of Individuals Covered	728
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $2,651
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 $229,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,007
Insurance broker organization code?	3

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

Policy contract number

30041741

Policy instance

Insurance contract or identification number	30041741
Number of Individuals Covered	512
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $5,124
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 $69,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,124
Insurance broker organization code?	3

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

Policy contract number

GLUG0584H

Policy instance

Insurance contract or identification number	GLUG0584H
Number of Individuals Covered	10
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $533
Total amount of fees paid to insurance company	USD $319
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	ACCIDENTAL DEATH & 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 $5,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $533
Amount paid for insurance broker fees	319
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

932866

Policy instance

Insurance contract or identification number	932866
Number of Individuals Covered	818
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $36,510
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $368,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,510
Insurance broker organization code?	3

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

Policy contract number

GLTD0584H

Policy instance

Insurance contract or identification number	GLTD0584H
Number of Individuals Covered	8
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $293
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	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 $2,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $293
Amount paid for insurance broker fees	181
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

30041741

Policy instance

Insurance contract or identification number	30041741
Number of Individuals Covered	442
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $6,286
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 $62,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,286
Insurance broker organization code?	3

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

Policy contract number

GLTD0584H

Policy instance

Insurance contract or identification number	GLTD0584H
Number of Individuals Covered	11
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $415
Total amount of fees paid to insurance company	USD $134
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 $4,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $415
Amount paid for insurance broker fees	134
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

18875

Policy instance

Insurance contract or identification number	18875
Number of Individuals Covered	393
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $140,673
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	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 $5,503,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $140,673
Insurance broker organization code?	3

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

Policy contract number

GLUG0584H

Policy instance

Insurance contract or identification number	GLUG0584H
Number of Individuals Covered	13
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $734
Total amount of fees paid to insurance company	USD $236
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	ACCIDENTAL DEATH & 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 $7,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $734
Amount paid for insurance broker fees	236
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

19007

Policy instance

Insurance contract or identification number	19007
Number of Individuals Covered	185
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $52,918
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	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 $1,773,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,918
Insurance broker organization code?	3

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

Policy contract number

22886

Policy instance

Insurance contract or identification number	22886
Number of Individuals Covered	728
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $12,970
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 $136,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,723
Insurance broker organization code?	3

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

Policy contract number

800006

Policy instance

Insurance contract or identification number	800006
Number of Individuals Covered	690
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $3,308
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	ACCIDENTAL DEATH & 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 $154,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,308
Insurance broker organization code?	3

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

Policy contract number

800007

Policy instance

Insurance contract or identification number	800007
Number of Individuals Covered	48
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $1,243
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
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $8,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,243
Insurance broker organization code?	3

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

Policy contract number

5946398

Policy instance

Insurance contract or identification number	5946398
Number of Individuals Covered	1603
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $5,076
Total amount of fees paid to insurance company	USD $96
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	Yes
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 $174,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,076
Amount paid for insurance broker fees	96
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION, MARKETING FEES
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

19007

Policy instance

Insurance contract or identification number	19007
Number of Individuals Covered	163
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $50,338
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	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 $1,676,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

800006

Policy instance

Insurance contract or identification number	800006
Number of Individuals Covered	667
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $4,728
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	ACCIDENTAL DEATH & 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 $177,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

800007

Policy instance

Insurance contract or identification number	800007
Number of Individuals Covered	40
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $1,409
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	ACCIDENTAL DEATH & 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 $9,392
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

30041741

Policy instance

Insurance contract or identification number	30041741
Number of Individuals Covered	420
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $2,071
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 $61,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

KM05946398

Policy instance

Insurance contract or identification number	KM05946398
Number of Individuals Covered	1527
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $4,792
Total amount of fees paid to insurance company	USD $83
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	Yes
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 $202,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

18875

Policy instance

Insurance contract or identification number	18875
Number of Individuals Covered	394
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $141,984
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	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 $4,636,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

R0505404

Policy instance

Insurance contract or identification number	R0505404
Number of Individuals Covered	520
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $29,413
Total amount of fees paid to insurance company	USD $2,844
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP CRITICAL ILLNESS
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 $126,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,591
Amount paid for insurance broker fees	2844
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

19007

Policy instance

Insurance contract or identification number	19007
Number of Individuals Covered	156
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $74,724
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $2,421,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $74,724
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

GLUG0584H

Policy instance

Insurance contract or identification number	GLUG0584H
Number of Individuals Covered	16
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $1,085
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $10,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,085
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

800006

Policy instance

Insurance contract or identification number	800006
Number of Individuals Covered	705
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $3,975
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $110,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,975
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

30041741

Policy instance

Insurance contract or identification number	30041741
Number of Individuals Covered	388
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $1,890
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 $51,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,890
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0009914999

Policy instance

Insurance contract or identification number	0009914999
Number of Individuals Covered	701
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $59,741
Total amount of fees paid to insurance company	USD $4,817
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	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 $211,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,816
Amount paid for insurance broker fees	4817
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

800007

Policy instance

Insurance contract or identification number	800007
Number of Individuals Covered	78
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $2,279
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $16,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,279
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

GLTD0584H

Policy instance

Insurance contract or identification number	GLTD0584H
Number of Individuals Covered	16
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $666
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	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 $6,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $666
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

18875

Policy instance

Insurance contract or identification number	18875
Number of Individuals Covered	424
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $177,844
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $5,883,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $177,844
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

19007

Policy instance

Insurance contract or identification number	19007
Number of Individuals Covered	208
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $73,201
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $2,495,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $73,201
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

800006

Policy instance

Insurance contract or identification number	800006
Number of Individuals Covered	793
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $3,986
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $107,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,986
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

R0505404

Policy instance

Insurance contract or identification number	R0505404
Number of Individuals Covered	497
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $40,406
Total amount of fees paid to insurance company	USD $5,132
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP CRITICAL ILLNESS
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 $121,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,296
Amount paid for insurance broker fees	5132
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0009914999

Policy instance

Insurance contract or identification number	0009914999
Number of Individuals Covered	668
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $105,337
Total amount of fees paid to insurance company	USD $13,381
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	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 $207,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $73,731
Amount paid for insurance broker fees	13381
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

800007

Policy instance

Insurance contract or identification number	800007
Number of Individuals Covered	89
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $1,951
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $12,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,951
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

GLTD0584H

Policy instance

Insurance contract or identification number	GLTD0584H
Number of Individuals Covered	8
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $272
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	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 $2,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $272
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

GLUG0584H

Policy instance

Insurance contract or identification number	GLUG0584H
Number of Individuals Covered	8
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $448
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $4,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $448
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

30041741

Policy instance

Insurance contract or identification number	30041741
Number of Individuals Covered	406
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $1,864
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 $49,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,864
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

18875

Policy instance

Insurance contract or identification number	18875
Number of Individuals Covered	415
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $163,701
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $5,569,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $163,593
Insurance broker organization code?	3
Insurance broker name	FALLSVALE INSURANCE SERVICES

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

Policy contract number

R0505404

Policy instance

Insurance contract or identification number	R0505404
Number of Individuals Covered	342
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $60,721
Total amount of fees paid to insurance company	USD $7,882
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	GROUP CRITICAL ILLNESS
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 $91,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,521
Amount paid for insurance broker fees	7882
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

0009914999

Policy instance

Insurance contract or identification number	0009914999
Number of Individuals Covered	319
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $84,334
Total amount of fees paid to insurance company	USD $9,890
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	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 $93,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,030
Amount paid for insurance broker fees	9890
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

18875

Policy instance

Insurance contract or identification number	18875
Number of Individuals Covered	385
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $149,085
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $4,969,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $149,082
Insurance broker organization code?	3
Insurance broker name	FALLSVALE INSURANCE SERVICES

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

19007

Policy instance

Insurance contract or identification number	19007
Number of Individuals Covered	205
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $59,428
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $1,980,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,428
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

800006

Policy instance

Insurance contract or identification number	800006
Number of Individuals Covered	737
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $5,657
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $111,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,657
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

30041741

Policy instance

Insurance contract or identification number	30041741
Number of Individuals Covered	268
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $1,486
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 $33,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,486
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

19007

Policy instance

Insurance contract or identification number	19007
Number of Individuals Covered	228
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $63,145
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $1,971,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,319
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

18875

Policy instance

Insurance contract or identification number	18875
Number of Individuals Covered	343
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $113,164
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $3,517,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,249
Insurance broker organization code?	3
Insurance broker name	MW BAGNALL COMPANY

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

Policy contract number

9322573135

Policy instance

Insurance contract or identification number	9322573135
Number of Individuals Covered	366
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
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?	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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $94,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9322573136

Policy instance

Insurance contract or identification number	9322573136
Number of Individuals Covered	271
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
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?	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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $47,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

A019007

Policy instance

Insurance contract or identification number	A019007
Number of Individuals Covered	299
Insurance policy start date	2011-09-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $16,353
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $60,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

A018875

Policy instance

Insurance contract or identification number	A018875
Number of Individuals Covered	284
Insurance policy start date	2011-09-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $27,471
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $101,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

19007

Policy instance

Insurance contract or identification number	19007
Number of Individuals Covered	253
Insurance policy start date	2011-09-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $119,135
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $2,166,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

18875

Policy instance

Insurance contract or identification number	18875
Number of Individuals Covered	341
Insurance policy start date	2011-09-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $209,108
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	Yes
Dental Insurance Welfare Benefit	Yes
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 $3,801,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	COLORADO RIVER INDIAN TRIBES
Employer identification number (EIN):	860092226
NAIC Classification:	921000

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
505	2022-09-01	AMELIA FLORES	2024-02-20
505	2021-09-01	AMELIA FLORES	2023-03-06
505	2020-09-01
505	2019-09-01
505	2018-09-01
505	2017-09-01
505	2016-09-01	DENNIS PATCH
505	2015-09-01	DENNIS PATCH
505	2014-09-01	DENNIS PATCH
505	2013-09-01	DENNIS PATCH
505	2012-09-01	DENNIS PATCH
505	2011-09-01	DENNIS PATCH