SKILS'KIN, INC. has sponsored the creation of one or more 401k plans.
Additional information about SKILS'KIN, INC.
Submission information for form 5500 for 401k plan SKILSKIN HEALTH & WELFARE PLAN
| Measure | Date | Value |
|---|
| 2018 : SKILSKIN HEALTH & WELFARE PLAN 2018 401k financial data |
|---|
| Transfers to/from the plan | 2018-12-31 | $-32,555 |
| Total plan liabilities at end of year | 2018-12-31 | $0 |
| Total plan liabilities at beginning of year | 2018-12-31 | $41,067 |
| Total income from all sources | 2018-12-31 | $0 |
| Expenses. Total of all expenses incurred | 2018-12-31 | $-28,588 |
| Benefits paid (including direct rollovers) | 2018-12-31 | $9,732 |
| Total plan assets at end of year | 2018-12-31 | $0 |
| Total plan assets at beginning of year | 2018-12-31 | $45,034 |
| Value of fidelity bond covering the plan | 2018-12-31 | $20,000 |
| Total contributions received or receivable from participants | 2018-12-31 | $0 |
| Expenses. Other expenses not covered elsewhere | 2018-12-31 | $1,000 |
| Contributions received from other sources (not participants or employers) | 2018-12-31 | $0 |
| Net income (gross income less expenses) | 2018-12-31 | $28,588 |
| Net plan assets at end of year (total assets less liabilities) | 2018-12-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2018-12-31 | $3,967 |
| Total contributions received or receivable from employer(s) | 2018-12-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2018-12-31 | $-39,320 |
| 2015 : SKILSKIN HEALTH & WELFARE PLAN 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $64,565 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $110,419 |
| Total income from all sources (including contributions) | 2015-12-31 | $613,467 |
| Total loss/gain on sale of assets | 2015-12-31 | $0 |
| Total of all expenses incurred | 2015-12-31 | $651,449 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $509,959 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $613,467 |
| Value of total assets at end of year | 2015-12-31 | $172,549 |
| Value of total assets at beginning of year | 2015-12-31 | $256,385 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $141,490 |
| Total interest from all sources | 2015-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | Yes |
| Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan | 2015-12-31 | $0 |
| Administrative expenses professional fees incurred | 2015-12-31 | $16,279 |
| Was this plan covered by a fidelity bond | 2015-12-31 | Yes |
| Value of fidelity bond cover | 2015-12-31 | $65,000 |
| If this is an individual account plan, was there a blackout period | 2015-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2015-12-31 | $27,222 |
| Administrative expenses (other) incurred | 2015-12-31 | $47,010 |
| Liabilities. Value of operating payables at end of year | 2015-12-31 | $22,293 |
| Liabilities. Value of operating payables at beginning of year | 2015-12-31 | $42,804 |
| Total non interest bearing cash at end of year | 2015-12-31 | $87,148 |
| Total non interest bearing cash at beginning of year | 2015-12-31 | $191,172 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $-37,982 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $107,984 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $145,966 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $375,175 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $613,467 |
| Employer contributions (assets) at end of year | 2015-12-31 | $58,179 |
| Employer contributions (assets) at beginning of year | 2015-12-31 | $65,213 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-12-31 | $134,784 |
| Contract administrator fees | 2015-12-31 | $78,201 |
| Liabilities. Value of benefit claims payable at end of year | 2015-12-31 | $42,272 |
| Liabilities. Value of benefit claims payable at beginning of year | 2015-12-31 | $67,615 |
| Did the plan have assets held for investment | 2015-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Unqualified |
| Accountancy firm name | 2015-12-31 | INEICH & COMPANY, LLP |
| Accountancy firm EIN | 2015-12-31 | 562552172 |
| 2014 : SKILSKIN HEALTH & WELFARE PLAN 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $110,419 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $81,560 |
| Total income from all sources (including contributions) | 2014-12-31 | $670,818 |
| Total loss/gain on sale of assets | 2014-12-31 | $0 |
| Total of all expenses incurred | 2014-12-31 | $666,149 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-12-31 | $498,951 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-12-31 | $670,818 |
| Value of total assets at end of year | 2014-12-31 | $256,385 |
| Value of total assets at beginning of year | 2014-12-31 | $222,857 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-12-31 | $167,198 |
| Total interest from all sources | 2014-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-12-31 | No |
| Administrative expenses professional fees incurred | 2014-12-31 | $14,711 |
| Was this plan covered by a fidelity bond | 2014-12-31 | Yes |
| Value of fidelity bond cover | 2014-12-31 | $65,000 |
| If this is an individual account plan, was there a blackout period | 2014-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-12-31 | No |
| Administrative expenses (other) incurred | 2014-12-31 | $65,119 |
| Liabilities. Value of operating payables at end of year | 2014-12-31 | $42,804 |
| Liabilities. Value of operating payables at beginning of year | 2014-12-31 | $25,312 |
| Total non interest bearing cash at end of year | 2014-12-31 | $191,172 |
| Total non interest bearing cash at beginning of year | 2014-12-31 | $158,738 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Value of net income/loss | 2014-12-31 | $4,669 |
| Value of net assets at end of year (total assets less liabilities) | 2014-12-31 | $145,966 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-12-31 | $141,297 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-12-31 | $358,542 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-12-31 | No |
| Contributions received in cash from employer | 2014-12-31 | $670,818 |
| Employer contributions (assets) at end of year | 2014-12-31 | $65,213 |
| Employer contributions (assets) at beginning of year | 2014-12-31 | $64,119 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-12-31 | $140,409 |
| Contract administrator fees | 2014-12-31 | $87,368 |
| Liabilities. Value of benefit claims payable at end of year | 2014-12-31 | $67,615 |
| Liabilities. Value of benefit claims payable at beginning of year | 2014-12-31 | $56,248 |
| Did the plan have assets held for investment | 2014-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-12-31 | Unqualified |
| Accountancy firm name | 2014-12-31 | INEICH & COMPANY, LLP |
| Accountancy firm EIN | 2014-12-31 | 562552172 |
| 2013 : SKILSKIN HEALTH & WELFARE PLAN 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $81,560 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $93,459 |
| Total income from all sources (including contributions) | 2013-12-31 | $706,460 |
| Total loss/gain on sale of assets | 2013-12-31 | $0 |
| Total of all expenses incurred | 2013-12-31 | $711,596 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-12-31 | $487,248 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-12-31 | $706,460 |
| Value of total assets at end of year | 2013-12-31 | $222,857 |
| Value of total assets at beginning of year | 2013-12-31 | $239,892 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-12-31 | $224,348 |
| Total interest from all sources | 2013-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-12-31 | No |
| Administrative expenses professional fees incurred | 2013-12-31 | $8,200 |
| Was this plan covered by a fidelity bond | 2013-12-31 | Yes |
| Value of fidelity bond cover | 2013-12-31 | $30,000 |
| If this is an individual account plan, was there a blackout period | 2013-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-12-31 | No |
| Income. Received or receivable in cash from other sources (including rollovers) | 2013-12-31 | $157 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2013-12-31 | $30,286 |
| Liabilities. Value of operating payables at end of year | 2013-12-31 | $25,312 |
| Liabilities. Value of operating payables at beginning of year | 2013-12-31 | $23,456 |
| Total non interest bearing cash at end of year | 2013-12-31 | $158,738 |
| Total non interest bearing cash at beginning of year | 2013-12-31 | $165,762 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Value of net income/loss | 2013-12-31 | $-5,136 |
| Value of net assets at end of year (total assets less liabilities) | 2013-12-31 | $141,297 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-12-31 | $146,433 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-12-31 | No |
| Investment advisory and management fees | 2013-12-31 | $92,826 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-12-31 | $336,883 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-12-31 | No |
| Contributions received in cash from employer | 2013-12-31 | $706,303 |
| Employer contributions (assets) at end of year | 2013-12-31 | $64,119 |
| Employer contributions (assets) at beginning of year | 2013-12-31 | $74,130 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-12-31 | $120,079 |
| Contract administrator fees | 2013-12-31 | $123,322 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2013-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2013-12-31 | $56,248 |
| Liabilities. Value of benefit claims payable at beginning of year | 2013-12-31 | $70,003 |
| Did the plan have assets held for investment | 2013-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-12-31 | Unqualified |
| Accountancy firm name | 2013-12-31 | INEICH & COMPANY, LLP |
| Accountancy firm EIN | 2013-12-31 | 562552172 |
| 2012 : SKILSKIN HEALTH & WELFARE PLAN 2012 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2012-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $93,459 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $80,071 |
| Total income from all sources (including contributions) | 2012-12-31 | $842,165 |
| Total loss/gain on sale of assets | 2012-12-31 | $0 |
| Total of all expenses incurred | 2012-12-31 | $783,713 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-12-31 | $558,101 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-12-31 | $842,165 |
| Value of total assets at end of year | 2012-12-31 | $239,892 |
| Value of total assets at beginning of year | 2012-12-31 | $168,052 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-12-31 | $225,612 |
| Total interest from all sources | 2012-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-12-31 | No |
| Administrative expenses professional fees incurred | 2012-12-31 | $216 |
| Was this plan covered by a fidelity bond | 2012-12-31 | Yes |
| Value of fidelity bond cover | 2012-12-31 | $30,000 |
| If this is an individual account plan, was there a blackout period | 2012-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-12-31 | No |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2012-12-31 | $24,717 |
| Administrative expenses (other) incurred | 2012-12-31 | $99,832 |
| Liabilities. Value of operating payables at end of year | 2012-12-31 | $23,456 |
| Liabilities. Value of operating payables at beginning of year | 2012-12-31 | $15,797 |
| Total non interest bearing cash at end of year | 2012-12-31 | $165,762 |
| Total non interest bearing cash at beginning of year | 2012-12-31 | $98,250 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Value of net income/loss | 2012-12-31 | $58,452 |
| Value of net assets at end of year (total assets less liabilities) | 2012-12-31 | $146,433 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-12-31 | $87,981 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-12-31 | No |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-12-31 | $1,691 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-12-31 | $1,691 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-12-31 | $330,815 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-12-31 | No |
| Contributions received in cash from employer | 2012-12-31 | $842,165 |
| Employer contributions (assets) at end of year | 2012-12-31 | $74,130 |
| Employer contributions (assets) at beginning of year | 2012-12-31 | $68,111 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-12-31 | $202,569 |
| Contract administrator fees | 2012-12-31 | $125,564 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2012-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2012-12-31 | $70,003 |
| Liabilities. Value of benefit claims payable at beginning of year | 2012-12-31 | $64,274 |
| Did the plan have assets held for investment | 2012-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-12-31 | Unqualified |
| Accountancy firm name | 2012-12-31 | INEICH & COMPANY LLP |
| Accountancy firm EIN | 2012-12-31 | 562552172 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645619 |
| Policy instance | 1 |
| Insurance contract or identification number | GL645619 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645817 |
| Policy instance | 2 |
| Insurance contract or identification number | VAR645817 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL MMC SKL1 |
| Policy instance | 3 |
| Insurance contract or identification number | SSL MMC SKL1 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $124,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL LMB SKL 1 |
| Policy instance | 4 |
| Insurance contract or identification number | SSL LMB SKL 1 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $182,795 | | 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 | DP-337, DP-347 |
| Policy instance | 5 |
| Insurance contract or identification number | DP-337, DP-347 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $45,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | FCE0-001 (548) |
| Policy instance | 6 |
| Insurance contract or identification number | FCE0-001 (548) | | Number of Individuals Covered | 123 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,920 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645817 |
| Policy instance | 2 |
| Insurance contract or identification number | VAR645817 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $222 | | Total amount of fees paid to insurance company | USD $41 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,217 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 41 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $222 | | Insurance broker name | PORTER, STEVE & BECKMAN, GARY |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645619 |
| Policy instance | 1 |
| Insurance contract or identification number | GL645619 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $1,365 | | Total amount of fees paid to insurance company | USD $259 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,654 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 259 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $1,365 | | Insurance broker name | PORTER, STEVE & BECKMAN, GARY |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL MMC LG SKI1 |
| Policy instance | 3 |
| Insurance contract or identification number | SSL MMC LG SKI1 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $82,214 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL LMB SKI 4 |
| Policy instance | 4 |
| Insurance contract or identification number | SSL LMB SKI 4 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-07-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $71,888 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL LMB SKI 5 |
| Policy instance | 5 |
| Insurance contract or identification number | SSL LMB SKI 5 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $221,356 | | 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 | DP-337, DP-347 |
| Policy instance | 6 |
| Insurance contract or identification number | DP-337, DP-347 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 8023900 |
| Policy instance | 1 |
| Insurance contract or identification number | 8023900 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $25,123 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $607,656 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 ) |
| Policy contract number | 548 |
| Policy instance | 7 |
| Insurance contract or identification number | 548 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 8023900 |
| Policy instance | 1 |
| Insurance contract or identification number | 8023900 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $26,929 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $638,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL LMB SKI 2 |
| Policy instance | 3 |
| Insurance contract or identification number | SSL LMB SKI 2 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $250,391 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645619 |
| Policy instance | 1 |
| Insurance contract or identification number | GL645619 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $1,496 | | Total amount of fees paid to insurance company | USD $129 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 129 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $1,496 | | Insurance broker name | FCE BENEFIT AMDINISTRATORS INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645817 |
| Policy instance | 2 |
| Insurance contract or identification number | VAR645817 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $219 | | Total amount of fees paid to insurance company | USD $24 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH DISMENBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,186 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 24 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $219 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 ) |
| Policy contract number | SSL LMB SKI 1 |
| Policy instance | 3 |
| Insurance contract or identification number | SSL LMB SKI 1 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $280,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR645817 |
| Policy instance | 2 |
| Insurance contract or identification number | VAR645817 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $24 | | Total amount of fees paid to insurance company | USD $205 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH DISMENBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,051 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 205 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $24 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL645619 |
| Policy instance | 1 |
| Insurance contract or identification number | GL645619 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $130 | | Total amount of fees paid to insurance company | USD $1,296 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1296 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER POLICY RELATED SERVICE FEES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $130 | | Insurance broker name | FCE BENEFIT AMDINISTRATORS INC. |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 8023900 |
| Policy instance | 1 |
| Insurance contract or identification number | 8023900 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $23,716 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $652,684 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
