HACI MECHANICAL CONTRACTORS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN
| 2023: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | Yes |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: HACI MECHANICAL CONTRACTORS, INC. PREMIUM CONV. FLEXIBLE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 82073 |
| Policy instance | 7 |
| Insurance contract or identification number | 82073 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $11,143 | | 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 | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $55,722 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-46405 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-46405 | | Number of Individuals Covered | 228 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $6,658 | | Total amount of fees paid to insurance company | USD $427 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,221 | | 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 | 5392418 |
| Policy instance | 2 |
| Insurance contract or identification number | 5392418 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,395 | | Total amount of fees paid to insurance company | USD $267 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18906 |
| Policy instance | 3 |
| Insurance contract or identification number | 18906 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $445 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,559 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| METROPOLITAN GENERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 39950 ) |
| Policy contract number | 8210010 |
| Policy instance | 4 |
| Insurance contract or identification number | 8210010 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $704 | | Total amount of fees paid to insurance company | USD $68 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $7,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00637681 |
| Policy instance | 5 |
| Insurance contract or identification number | 00637681 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $69,400 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $287,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B4WS |
| Policy instance | 6 |
| Insurance contract or identification number | GLUG0B4WS | | Number of Individuals Covered | 468 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $25,945 | | Total amount of fees paid to insurance company | USD $18,335 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $172,966 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-46405 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-46405 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $7,890 | | Total amount of fees paid to insurance company | USD $1,002 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,628 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 906482 |
| Policy instance | 2 |
| Insurance contract or identification number | 906482 | | Number of Individuals Covered | 256 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $63,488 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,228,242 | | 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 | 5392418 |
| Policy instance | 3 |
| Insurance contract or identification number | 5392418 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,457 | | Total amount of fees paid to insurance company | USD $222 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18906 |
| Policy instance | 4 |
| Insurance contract or identification number | 18906 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $582 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,270 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 ) |
| Policy contract number | 8000010 |
| Policy instance | 5 |
| Insurance contract or identification number | 8000010 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN GENERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 39950 ) |
| Policy contract number | 8210010 |
| Policy instance | 6 |
| Insurance contract or identification number | 8210010 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $239 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $2,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B4WS |
| Policy instance | 7 |
| Insurance contract or identification number | GLUG0B4WS | | Number of Individuals Covered | 194 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $23,775 | | Total amount of fees paid to insurance company | USD $17,303 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $158,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 82073 |
| Policy instance | 8 |
| Insurance contract or identification number | 82073 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,078 | | 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 | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $53,912 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-46405 |
| Policy instance | 1 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 906482 |
| Policy instance | 2 |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 73010 |
| Policy instance | 3 |
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18906 |
| Policy instance | 4 |
| METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 ) |
| Policy contract number | 8000010 |
| Policy instance | 5 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B4WS |
| Policy instance | 6 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 82073 |
| Policy instance | 7 |
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-46405 |
| Policy instance | 1 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 906482 |
| Policy instance | 2 |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 73010 |
| Policy instance | 3 |
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18906 |
| Policy instance | 4 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGB4WS |
| Policy instance | 5 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 82073 |
| Policy instance | 6 |
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-46405 |
| Policy instance | 1 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 906482 |
| Policy instance | 2 |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 73010 |
| Policy instance | 3 |
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18906 |
| Policy instance | 4 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGB4WS |
| Policy instance | 5 |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 82073 |
| Policy instance | 6 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B4WS |
| Policy instance | 5 |
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18906 |
| Policy instance | 4 |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 73010 |
| Policy instance | 3 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 906482 |
| Policy instance | 2 |
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-46405 |
| Policy instance | 1 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000B4WS |
| Policy instance | 4 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785221 |
| Policy instance | 3 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 906482 |
| Policy instance | 2 |
| AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 ) |
| Policy contract number | 10001085 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 804539 |
| Policy instance | 1 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785221 |
| Policy instance | 2 |
| AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 ) |
| Policy contract number | 10001085 |
| Policy instance | 3 |
| AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 ) |
| Policy contract number | 10001085 |
| Policy instance | 5 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785221 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601912* |
| Policy instance | 2 |
| AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 ) |
| Policy contract number | 10001085 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 804539 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 804539 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601912* |
| Policy instance | 3 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785221 |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 804539 |
| Policy instance | 6 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | GP-500B |
| Policy instance | 1 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785221 |
| Policy instance | 2 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 10001085 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601912* |
| Policy instance | 4 |
| AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 ) |
| Policy contract number | 10001085 |
| Policy instance | 5 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785221 |
| Policy instance | 2 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 10001085 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601912* |
| Policy instance | 4 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | GP-AFA12002070 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601912* |
| Policy instance | 2 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785221 |
| Policy instance | 3 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 10001085 |
| Policy instance | 4 |
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 28063 |
| Policy instance | 1 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 703211 |
| Policy instance | 5 |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1007879 |
| Policy instance | 4 |
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 10001085 |
| Policy instance | 3 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 302304 |
| Policy instance | 2 |
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 28063 |
| Policy instance | 1 |
