401k Plan data: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN plan

PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN
Plan identification number	503

PACECOM HOLDINGS, INC. 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) Prepaid legal Long-term disability cover Severance pay Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

PACECOM HOLDINGS, INC. has sponsored the creation of one or more 401k plans.

Company Name: PACECOM HOLDINGS, INC.

Employer identification number (EIN): 900218111

NAIC Classification: 511120
NAIC Description: Periodical Publishers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-07-01
503 2021-07-01
503 2020-07-01
503 2019-07-01
503 2018-07-01
503 2017-07-01 LEIGH ANN KLEE
503 2016-07-01 LEIGH ANN KLEE
503 2015-07-01 LEIGH ANN KLEE
503 2014-07-01 LEIGH ANN KLEE
503 2013-07-01 LEIGH ANN KLEE
503 2013-03-01 LEIGH ANN KLEE
503 2012-03-01 LEIGH ANN KLEE

Plan Statistics for PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN

Measure Date Value
2022: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 270
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 249
Number of retired or separated participants receiving benefits 2022-07-01 3
Total of all active and inactive participants 2022-07-01 252
2021: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 289
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 270
Number of retired or separated participants receiving benefits 2021-07-01 2
Total of all active and inactive participants 2021-07-01 272
2020: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 226
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 289
Total of all active and inactive participants 2020-07-01 289
2019: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 241
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 212
Number of retired or separated participants receiving benefits 2019-07-01 14
Total of all active and inactive participants 2019-07-01 226
2018: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 233
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 241
Total of all active and inactive participants 2018-07-01 241
2017: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 239
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 233
Total of all active and inactive participants 2017-07-01 233
2016: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 254
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 239
Total of all active and inactive participants 2016-07-01 239
2015: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 291
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 254
Total of all active and inactive participants 2015-07-01 254
2014: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 280
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 291
Total of all active and inactive participants 2014-07-01 291
2013: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 261
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 280
Total of all active and inactive participants 2013-07-01 280
Total participants, beginning-of-year 2013-03-01 256
Total number of active participants reported on line 7a of the Form 5500 2013-03-01 261
Total of all active and inactive participants 2013-03-01 261
2012: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-03-01 195
Total number of active participants reported on line 7a of the Form 5500 2012-03-01 256
Total of all active and inactive participants 2012-03-01 256

Measure	Date	Value
2022: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	270
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	249
Number of retired or separated participants receiving benefits	2022-07-01	3
Total of all active and inactive participants	2022-07-01	252
2021: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	289
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	270
Number of retired or separated participants receiving benefits	2021-07-01	2
Total of all active and inactive participants	2021-07-01	272
2020: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	226
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	289
Total of all active and inactive participants	2020-07-01	289
2019: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	241
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	212
Number of retired or separated participants receiving benefits	2019-07-01	14
Total of all active and inactive participants	2019-07-01	226
2018: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	233
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	241
Total of all active and inactive participants	2018-07-01	241
2017: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	239
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	233
Total of all active and inactive participants	2017-07-01	233
2016: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	254
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	239
Total of all active and inactive participants	2016-07-01	239
2015: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	291
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	254
Total of all active and inactive participants	2015-07-01	254
2014: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	280
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	291
Total of all active and inactive participants	2014-07-01	291
2013: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	261
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	280
Total of all active and inactive participants	2013-07-01	280
Total participants, beginning-of-year	2013-03-01	256
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	261
Total of all active and inactive participants	2013-03-01	261
2012: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-03-01	195
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	256
Total of all active and inactive participants	2012-03-01	256

Form 5500 Responses for PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN

2022: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: PACECOM HOLDINGS, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	144
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $1,226
Total amount of fees paid to insurance company	USD $681
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,226
Amount paid for insurance broker fees	681
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417011411450

Policy instance

Insurance contract or identification number	417011411450
Number of Individuals Covered	128
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $19,026
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

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	144
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $3,060
Total amount of fees paid to insurance company	USD $1,661
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,060
Amount paid for insurance broker fees	1661
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	54
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $2,662
Total amount of fees paid to insurance company	USD $1,430
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,662
Amount paid for insurance broker fees	1430
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

417012411450

Policy instance

Insurance contract or identification number	417012411450
Number of Individuals Covered	128
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $11,583
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $215,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,583
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

10213551001

Policy instance

Insurance contract or identification number	10213551001
Number of Individuals Covered	174
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $1,591
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,591
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

204107

Policy instance

Insurance contract or identification number	204107
Number of Individuals Covered	24
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $971
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $5,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $971
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

Policy instance

Number of Individuals Covered	129
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

10140

Policy instance

Insurance contract or identification number	10140
Number of Individuals Covered	249
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10213561001

Policy instance

Insurance contract or identification number	10213561001
Number of Individuals Covered	3
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $199
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

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	58
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $2,616
Total amount of fees paid to insurance company	USD $1,120
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,616
Amount paid for insurance broker fees	1120
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	155
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $1,354
Total amount of fees paid to insurance company	USD $649
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,354
Amount paid for insurance broker fees	649
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417011411450

Policy instance

Insurance contract or identification number	417011411450
Number of Individuals Covered	133
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $20,599
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

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	154
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $3,173
Total amount of fees paid to insurance company	USD $1,592
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,173
Amount paid for insurance broker fees	1592
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

STHEALTH/CHARTIS (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

417009411450

Policy instance

Insurance contract or identification number	417009411450
Number of Individuals Covered	133
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $9,820
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $213,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,789
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

10213551001

Policy instance

Insurance contract or identification number	10213551001
Number of Individuals Covered	194
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,537
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,537
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

204107

Policy instance

Insurance contract or identification number	204107
Number of Individuals Covered	26
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,141
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $6,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,141
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

Policy instance

Number of Individuals Covered	133
Insurance policy start date	2021-07-01
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

10140

Policy instance

Insurance contract or identification number	10140
Number of Individuals Covered	270
Insurance policy start date	2021-07-01
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
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10213561001

Policy instance

Insurance contract or identification number	10213561001
Number of Individuals Covered	2
Insurance policy start date	2021-07-01
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
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $213
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

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	61
Insurance policy start date	2020-07-01
Insurance policy end date	2021-07-01
Total amount of commissions paid to insurance broker	USD $2,404
Total amount of fees paid to insurance company	USD $1,361
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,404
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	158
Insurance policy start date	2020-07-01
Insurance policy end date	2021-07-01
Total amount of commissions paid to insurance broker	USD $1,144
Total amount of fees paid to insurance company	USD $510
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,144
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417008411450

Policy instance

Insurance contract or identification number	417008411450
Number of Individuals Covered	137
Insurance policy start date	2020-07-01
Insurance policy end date	2021-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $22,033
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

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	158
Insurance policy start date	2020-07-01
Insurance policy end date	2021-07-01
Total amount of commissions paid to insurance broker	USD $2,978
Total amount of fees paid to insurance company	USD $1,321
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,978
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

417007411450

Policy instance

Insurance contract or identification number	417007411450
Number of Individuals Covered	137
Insurance policy start date	2020-07-01
Insurance policy end date	2021-07-01
Total amount of commissions paid to insurance broker	USD $10,007
Total amount of fees paid to insurance company	USD $4,981
Welfare Benefit Premiums Paid to Carrier	USD $198,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,007
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS PAYMENT

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

Policy contract number

10213551001

Policy instance

Insurance contract or identification number	10213551001
Number of Individuals Covered	192
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,532
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,532
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

10213561001

Policy instance

Insurance contract or identification number	10213561001
Number of Individuals Covered	0
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

204107

Policy instance

Insurance contract or identification number	204107
Number of Individuals Covered	22
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $887
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $5,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $887
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

Policy instance

Number of Individuals Covered	145
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

10140

Policy instance

Insurance contract or identification number	10140
Number of Individuals Covered	289
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $1,500
Dental Insurance Welfare Benefit	Yes
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	1500
Additional information about fees paid to insurance broker	NEW BUSINESS BONUS
Insurance broker organization code?	3

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	170
Insurance policy start date	2019-07-01
Insurance policy end date	2020-07-01
Total amount of commissions paid to insurance broker	USD $1,450
Total amount of fees paid to insurance company	USD $982
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,450
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	73
Insurance policy start date	2019-07-01
Insurance policy end date	2020-07-01
Total amount of commissions paid to insurance broker	USD $4,781
Total amount of fees paid to insurance company	USD $3,450
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,781
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

417007411450

Policy instance

Insurance contract or identification number	417007411450
Number of Individuals Covered	162
Insurance policy start date	2019-07-01
Insurance policy end date	2020-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $193,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10213551001

Policy instance

Insurance contract or identification number	10213551001
Number of Individuals Covered	212
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,739
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,739
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

10213561001

Policy instance

Insurance contract or identification number	10213561001
Number of Individuals Covered	14
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

204107

Policy instance

Insurance contract or identification number	204107
Number of Individuals Covered	25
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,105
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LEGAL SERVICES PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to Carrier	USD $6,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,105
Amount paid for insurance broker fees	0
Insurance broker organization code?	4

RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

Policy instance

Number of Individuals Covered	186
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	170
Insurance policy start date	2019-07-01
Insurance policy end date	2020-07-01
Total amount of commissions paid to insurance broker	USD $3,725
Total amount of fees paid to insurance company	USD $2,404
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $37,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,725
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417008411450

Policy instance

Insurance contract or identification number	417008411450
Number of Individuals Covered	162
Insurance policy start date	2019-07-01
Insurance policy end date	2020-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $25,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

417004411450

Policy instance

Insurance contract or identification number	417004411450
Number of Individuals Covered	189
Insurance policy start date	2018-07-01
Insurance policy end date	2019-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $26,707
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

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	217
Insurance policy start date	2018-07-01
Insurance policy end date	2019-07-01
Total amount of commissions paid to insurance broker	USD $1,726
Total amount of fees paid to insurance company	USD $1,036
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,726
Insurance broker organization code?	3
Amount paid for insurance broker fees	1036
Additional information about fees paid to insurance broker	OTHER COMPENSATION

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

Policy contract number

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	217
Insurance policy start date	2018-07-01
Insurance policy end date	2019-07-01
Total amount of commissions paid to insurance broker	USD $4,202
Total amount of fees paid to insurance company	USD $2,509
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,202
Amount paid for insurance broker fees	2509
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	48
Insurance policy start date	2018-07-01
Insurance policy end date	2019-07-01
Total amount of commissions paid to insurance broker	USD $2,511
Total amount of fees paid to insurance company	USD $1,447
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,511
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OTHER COMPENSATION

COMMUNITY EYE CARE (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

TP035012

Policy instance

Insurance contract or identification number	TP035012
Number of Individuals Covered	239
Insurance policy start date	2018-07-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

417007411450

Policy instance

Insurance contract or identification number	417007411450
Number of Individuals Covered	189
Insurance policy start date	2018-07-01
Insurance policy end date	2019-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $238,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

10213551001

Policy instance

Insurance contract or identification number	10213551001
Number of Individuals Covered	241
Insurance policy start date	2019-02-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $587
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $587
Insurance broker organization code?	3

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

417004411450

Policy instance

Insurance contract or identification number	417004411450
Number of Individuals Covered	199
Insurance policy start date	2017-07-01
Insurance policy end date	2018-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $25,920
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

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	232
Insurance policy start date	2017-07-01
Insurance policy end date	2018-07-01
Total amount of commissions paid to insurance broker	USD $4,137
Total amount of fees paid to insurance company	USD $1,042
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,137
Amount paid for insurance broker fees	1042
Additional information about fees paid to insurance broker	OTHER COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	233
Insurance policy start date	2017-07-01
Insurance policy end date	2018-07-01
Total amount of commissions paid to insurance broker	USD $1,771
Total amount of fees paid to insurance company	USD $446
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $17,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,771
Amount paid for insurance broker fees	446
Additional information about fees paid to insurance broker	OTHER COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	47
Insurance policy start date	2017-07-01
Insurance policy end date	2018-07-01
Total amount of commissions paid to insurance broker	USD $2,315
Total amount of fees paid to insurance company	USD $493
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,315
Amount paid for insurance broker fees	493
Additional information about fees paid to insurance broker	OTHER COMPENSATION PAID
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

COMMUNITY EYE CARE (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

TP035012

Policy instance

Insurance contract or identification number	TP035012
Number of Individuals Covered	230
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417006411450

Policy instance

Insurance contract or identification number	417006411450
Number of Individuals Covered	199
Insurance policy start date	2017-07-01
Insurance policy end date	2018-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $285,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

417003411450

Policy instance

Insurance contract or identification number	417003411450
Number of Individuals Covered	207
Insurance policy start date	2015-07-01
Insurance policy end date	2016-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $30,711
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

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	254
Insurance policy start date	2015-07-01
Insurance policy end date	2016-07-01
Total amount of commissions paid to insurance broker	USD $4,479
Total amount of fees paid to insurance company	USD $1,650
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,479
Amount paid for insurance broker fees	1650
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	254
Insurance policy start date	2015-07-01
Insurance policy end date	2016-07-01
Total amount of commissions paid to insurance broker	USD $2,104
Total amount of fees paid to insurance company	USD $795
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,104
Amount paid for insurance broker fees	795
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	59
Insurance policy start date	2015-07-01
Insurance policy end date	2016-07-01
Total amount of commissions paid to insurance broker	USD $2,394
Total amount of fees paid to insurance company	USD $897
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,394
Amount paid for insurance broker fees	897
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417006411450

Policy instance

Insurance contract or identification number	417006411450
Number of Individuals Covered	207
Insurance policy start date	2015-07-01
Insurance policy end date	2016-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $212,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

417003411450

Policy instance

Insurance contract or identification number	417003411450
Number of Individuals Covered	245
Insurance policy start date	2014-07-01
Insurance policy end date	2015-07-01
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $274,736
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

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	290
Insurance policy start date	2014-07-01
Insurance policy end date	2015-07-01
Total amount of commissions paid to insurance broker	USD $4,587
Total amount of fees paid to insurance company	USD $2,117
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,587
Amount paid for insurance broker fees	2117
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	291
Insurance policy start date	2014-07-01
Insurance policy end date	2015-07-01
Total amount of commissions paid to insurance broker	USD $2,227
Total amount of fees paid to insurance company	USD $976
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,227
Amount paid for insurance broker fees	976
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	63
Insurance policy start date	2014-07-01
Insurance policy end date	2015-07-01
Total amount of commissions paid to insurance broker	USD $2,681
Total amount of fees paid to insurance company	USD $1,176
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,681
Amount paid for insurance broker fees	1176
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

G000558E

Policy instance

Insurance contract or identification number	G000558E
Number of Individuals Covered	63
Insurance policy start date	2013-07-01
Insurance policy end date	2014-07-01
Total amount of commissions paid to insurance broker	USD $2,563
Total amount of fees paid to insurance company	USD $542
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,563
Amount paid for insurance broker fees	542
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

G000558E

Policy instance

Insurance contract or identification number	G000558E
Number of Individuals Covered	280
Insurance policy start date	2013-07-01
Insurance policy end date	2014-07-01
Total amount of commissions paid to insurance broker	USD $2,213
Total amount of fees paid to insurance company	USD $529
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,213
Amount paid for insurance broker fees	529
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

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

Policy contract number

G000558R

Policy instance

Insurance contract or identification number	G000558R
Number of Individuals Covered	279
Insurance policy start date	2013-07-01
Insurance policy end date	2014-07-01
Total amount of commissions paid to insurance broker	USD $4,494
Total amount of fees paid to insurance company	USD $736
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,494
Amount paid for insurance broker fees	736
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

417003411450

Policy instance

Insurance contract or identification number	417003411450
Number of Individuals Covered	223
Insurance policy start date	2013-07-01
Insurance policy end date	2014-07-01
Total amount of commissions paid to insurance broker	USD $11,610
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $254,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,610
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC.

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

MLB000029-12

Policy instance

Insurance contract or identification number	MLB000029-12
Number of Individuals Covered	209
Insurance policy start date	2013-03-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,342
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $66,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,342
Insurance broker organization code?	3
Insurance broker name	STOP LOSS INSURANCE SERVICES, INC.

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

949-1209

Policy instance

Insurance contract or identification number	949-1209
Number of Individuals Covered	209
Insurance policy start date	2013-03-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $422
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $8,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $422
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	261
Insurance policy start date	2013-03-01
Insurance policy end date	2013-07-01
Total amount of commissions paid to insurance broker	USD $672
Total amount of fees paid to insurance company	USD $541
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $6,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $672
Amount paid for insurance broker fees	541
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC

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

Policy contract number

GUPR0558E

Policy instance

Insurance contract or identification number	GUPR0558E
Number of Individuals Covered	250
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $1,248
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,248
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC

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

Policy contract number

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	63
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $709
Total amount of fees paid to insurance company	USD $414
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $709
Amount paid for insurance broker fees	414
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC

WEB-TPA (National Association of Insurance Commissioners NAIC id number: 0 )

Policy contract number

Policy instance

Number of Individuals Covered	198
Insurance policy start date	2013-03-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	MEDICAL - SELF INSURED
Welfare Benefit Premiums Paid to Carrier	USD $479,448
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

GLTD0558E

Policy instance

Insurance contract or identification number	GLTD0558E
Number of Individuals Covered	256
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $3,227
Total amount of fees paid to insurance company	USD $697
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,576
Amount paid for insurance broker fees	697
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC

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

Policy contract number

GVTL0558E

Policy instance

Insurance contract or identification number	GVTL0558E
Number of Individuals Covered	61
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $1,870
Total amount of fees paid to insurance company	USD $398
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $926
Amount paid for insurance broker fees	398
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC

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

Policy contract number

GLUG0558E

Policy instance

Insurance contract or identification number	GLUG0558E
Number of Individuals Covered	256
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $2,421
Total amount of fees paid to insurance company	USD $533
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $24,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,193
Amount paid for insurance broker fees	533
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JAMES A. SCOTT & SON INC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

949-1209

Policy instance

Insurance contract or identification number	949-1209
Number of Individuals Covered	203
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $1,098
Total amount of fees paid to insurance company	USD $709
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	ORGAN TRANSPLANT
Welfare Benefit Premiums Paid to Carrier	USD $20,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,098
Amount paid for insurance broker fees	709
Additional information about fees paid to insurance broker	SERVICE ALLOWANCE
Insurance broker organization code?	3
Insurance broker name	STOP LOSS INSURANCE SERVICES, INC.

INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 )

Policy contract number

MLB000029-12

Policy instance

Insurance contract or identification number	MLB000029-12
Number of Individuals Covered	203
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $8,843
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $176,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,843
Insurance broker organization code?	3
Insurance broker name	STOP LOSS INSURANCE SERVICES, INC.

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Company Name:	PACECOM HOLDINGS, INC.
Employer identification number (EIN):	900218111
NAIC Classification:	511120
NAIC Description:	Periodical Publishers