401k Plan data: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS plan

SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 401k Plan overview

Plan Name	SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS
Plan identification number	502

SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS Benefits

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

401k Sponsoring company profile

THE POLICE CREDIT UNION OF CALIFORNIA has sponsored the creation of one or more 401k plans.

Company Name: THE POLICE CREDIT UNION OF CALIFORNIA

Employer identification number (EIN): 941278209

NAIC Classification: 522130
NAIC Description: Credit Unions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2022-01-01 NATALIE SIGNORELLI 2023-03-10
502 2021-01-01 NATALIE SIGNORELLI 2022-03-24
502 2020-01-01 NATALIE SIGNORELLI 2021-03-05
502 2020-01-01 NATALIE SIGNORELLI 2021-07-06
502 2019-01-01 NATALIE SIGNORELLI 2020-03-30
502 2019-01-01 NATALIE SIGNORELLI 2021-07-06
502 2018-01-01
502 2018-01-01 NATALIE SIGNORELLI 2021-07-06
502 2017-01-01
502 2017-01-01 NATALIE SIGNORELLI 2021-07-14
502 2016-01-01 DEIRDRE CLOHERTY
502 2016-01-01
502 2016-01-01 NATALIE SIGNORELLI 2021-07-06
502 2015-01-01
502 2015-01-01 NATALIE SIGNORELLI 2021-08-31
502 2014-01-01 DEIRDRE CLOHERTY
502 2014-01-01 NATALIE SIGNORELLI 2021-08-31
502 2013-01-01 DEIRDRE CLOHERTY
502 2013-01-01 NATALIE SIGNORELLI 2021-08-31

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
502	2022-01-01	NATALIE SIGNORELLI	2023-03-10
502	2021-01-01	NATALIE SIGNORELLI	2022-03-24
502	2020-01-01	NATALIE SIGNORELLI	2021-03-05
502	2020-01-01	NATALIE SIGNORELLI	2021-07-06
502	2019-01-01	NATALIE SIGNORELLI	2020-03-30
502	2019-01-01	NATALIE SIGNORELLI	2021-07-06
502	2018-01-01
502	2018-01-01	NATALIE SIGNORELLI	2021-07-06
502	2017-01-01
502	2017-01-01	NATALIE SIGNORELLI	2021-07-14
502	2016-01-01	DEIRDRE CLOHERTY
502	2016-01-01
502	2016-01-01	NATALIE SIGNORELLI	2021-07-06
502	2015-01-01
502	2015-01-01	NATALIE SIGNORELLI	2021-08-31
502	2014-01-01	DEIRDRE CLOHERTY
502	2014-01-01	NATALIE SIGNORELLI	2021-08-31
502	2013-01-01	DEIRDRE CLOHERTY
502	2013-01-01	NATALIE SIGNORELLI	2021-08-31

Plan Statistics for SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS

401k plan membership statisitcs for SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS

Measure Date Value
2022: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2022 401k membership
Total participants, beginning-of-year 2022-01-01 167
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 133
Number of retired or separated participants receiving benefits 2022-01-01 2
Number of other retired or separated participants entitled to future benefits 2022-01-01 14
Total of all active and inactive participants 2022-01-01 149
Number of employers contributing to the scheme 2022-01-01 0
2021: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2021 401k membership
Total participants, beginning-of-year 2021-01-01 139
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 133
Number of retired or separated participants receiving benefits 2021-01-01 3
Number of other retired or separated participants entitled to future benefits 2021-01-01 31
Total of all active and inactive participants 2021-01-01 167
Number of employers contributing to the scheme 2021-01-01 0
2020: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2020 401k membership
Total participants, beginning-of-year 2020-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 127
Number of retired or separated participants receiving benefits 2020-01-01 3
Number of other retired or separated participants entitled to future benefits 2020-01-01 9
Total of all active and inactive participants 2020-01-01 139
Number of employers contributing to the scheme 2020-01-01 0
2019: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2019 401k membership
Total participants, beginning-of-year 2019-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 116
Number of retired or separated participants receiving benefits 2019-01-01 3
Number of other retired or separated participants entitled to future benefits 2019-01-01 2
Total of all active and inactive participants 2019-01-01 121
Number of employers contributing to the scheme 2019-01-01 0
2018: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2018 401k membership
Total participants, beginning-of-year 2018-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 105
Number of retired or separated participants receiving benefits 2018-01-01 2
Number of other retired or separated participants entitled to future benefits 2018-01-01 2
Total of all active and inactive participants 2018-01-01 109
Number of employers contributing to the scheme 2018-01-01 0
2017: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2017 401k membership
Total participants, beginning-of-year 2017-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 111
Number of retired or separated participants receiving benefits 2017-01-01 1
Number of other retired or separated participants entitled to future benefits 2017-01-01 2
Total of all active and inactive participants 2017-01-01 114
Number of employers contributing to the scheme 2017-01-01 0
2016: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2016 401k membership
Total participants, beginning-of-year 2016-01-01 113
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 107
Number of retired or separated participants receiving benefits 2016-01-01 1
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 108
Number of employers contributing to the scheme 2016-01-01 0
2015: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2015 401k membership
Total participants, beginning-of-year 2015-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 104
Number of retired or separated participants receiving benefits 2015-01-01 4
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 108
2014: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2014 401k membership
Total participants, beginning-of-year 2014-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 102
Number of retired or separated participants receiving benefits 2014-01-01 5
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 107
2013: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2013 401k membership
Total participants, beginning-of-year 2013-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 107
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 107

Measure	Date	Value
2022: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2022 401k membership
Total participants, beginning-of-year	2022-01-01	167
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	133
Number of retired or separated participants receiving benefits	2022-01-01	2
Number of other retired or separated participants entitled to future benefits	2022-01-01	14
Total of all active and inactive participants	2022-01-01	149
Number of employers contributing to the scheme	2022-01-01	0
2021: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2021 401k membership
Total participants, beginning-of-year	2021-01-01	139
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	133
Number of retired or separated participants receiving benefits	2021-01-01	3
Number of other retired or separated participants entitled to future benefits	2021-01-01	31
Total of all active and inactive participants	2021-01-01	167
Number of employers contributing to the scheme	2021-01-01	0
2020: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2020 401k membership
Total participants, beginning-of-year	2020-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	127
Number of retired or separated participants receiving benefits	2020-01-01	3
Number of other retired or separated participants entitled to future benefits	2020-01-01	9
Total of all active and inactive participants	2020-01-01	139
Number of employers contributing to the scheme	2020-01-01	0
2019: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2019 401k membership
Total participants, beginning-of-year	2019-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	116
Number of retired or separated participants receiving benefits	2019-01-01	3
Number of other retired or separated participants entitled to future benefits	2019-01-01	2
Total of all active and inactive participants	2019-01-01	121
Number of employers contributing to the scheme	2019-01-01	0
2018: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2018 401k membership
Total participants, beginning-of-year	2018-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	105
Number of retired or separated participants receiving benefits	2018-01-01	2
Number of other retired or separated participants entitled to future benefits	2018-01-01	2
Total of all active and inactive participants	2018-01-01	109
Number of employers contributing to the scheme	2018-01-01	0
2017: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2017 401k membership
Total participants, beginning-of-year	2017-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	111
Number of retired or separated participants receiving benefits	2017-01-01	1
Number of other retired or separated participants entitled to future benefits	2017-01-01	2
Total of all active and inactive participants	2017-01-01	114
Number of employers contributing to the scheme	2017-01-01	0
2016: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2016 401k membership
Total participants, beginning-of-year	2016-01-01	113
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	107
Number of retired or separated participants receiving benefits	2016-01-01	1
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	108
Number of employers contributing to the scheme	2016-01-01	0
2015: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2015 401k membership
Total participants, beginning-of-year	2015-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	104
Number of retired or separated participants receiving benefits	2015-01-01	4
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	108
2014: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2014 401k membership
Total participants, beginning-of-year	2014-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	102
Number of retired or separated participants receiving benefits	2014-01-01	5
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	107
2013: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2013 401k membership
Total participants, beginning-of-year	2013-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	107
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	107

Form 5500 Responses for SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS

2022: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	Yes
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	Yes
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: SF POLICE CREDIT UNION EMPLOYEE HEALTH BENEFITS 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	First time form 5500 has been submitted	Yes
2013-01-01	Submission has been amended	Yes
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

169039

Policy instance

Insurance contract or identification number	169039
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 $32,738
Total amount of fees paid to insurance company	USD $5,506
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,255
Amount paid for insurance broker fees	5506
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605968

Policy instance

Insurance contract or identification number	605968
Number of Individuals Covered	79
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $28,451
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $685,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,451
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

15274873

Policy instance

Insurance contract or identification number	15274873
Number of Individuals Covered	128
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $103
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $6,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $103
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-72-48

Policy instance

Insurance contract or identification number	9906-72-48
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 $272
Total amount of fees paid to insurance company	USD $362
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Amount paid for insurance broker fees	362
Additional information about fees paid to insurance broker	STRAIGHT FEE - WHOLESALER/BROKER OF RECORD
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $272

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0066916

Policy instance

Insurance contract or identification number	W0066916
Number of Individuals Covered	52
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $11,621
Total amount of fees paid to insurance company	USD $29,897
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $552,004
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	29897
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0066916

Policy instance

Insurance contract or identification number	W0066916
Number of Individuals Covered	55
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $13,007
Total amount of fees paid to insurance company	USD $32,156
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $604,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $908
Amount paid for insurance broker fees	31527
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-72-48

Policy instance

Insurance contract or identification number	9906-72-48
Number of Individuals Covered	133
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $241
Total amount of fees paid to insurance company	USD $322
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	322
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605968

Policy instance

Insurance contract or identification number	605968
Number of Individuals Covered	73
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $26,030
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $520,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,030
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116722

Policy instance

Insurance contract or identification number	10116722
Number of Individuals Covered	133
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $24,759
Total amount of fees paid to insurance company	USD $15,544
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $202,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,759
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OVERRIDES, BROKER BONUS

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	128
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $302
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $5,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $302
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-72-48

Policy instance

Insurance contract or identification number	9906-72-48
Number of Individuals Covered	127
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $525
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $300
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0066916

Policy instance

Insurance contract or identification number	W0066916
Number of Individuals Covered	59
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $11,626
Total amount of fees paid to insurance company	USD $26,834
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $516,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $759
Amount paid for insurance broker fees	26834
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

1D034635

Policy instance

Insurance contract or identification number	1D034635
Number of Individuals Covered	79
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $9,689
Total amount of fees paid to insurance company	USD $8,470
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $96,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,689
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OVERRIDES BROKER BONUS

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	116
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $275
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $5,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $275
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605968

Policy instance

Insurance contract or identification number	605968
Number of Individuals Covered	56
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $22,149
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $445,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,149
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1907100

Policy instance

Insurance contract or identification number	1907100
Number of Individuals Covered	0
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $116
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $116
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116722

Policy instance

Insurance contract or identification number	10116722
Number of Individuals Covered	127
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $12,395
Total amount of fees paid to insurance company	USD $7,004
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $82,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,395
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OVERRIDES BROKER BONUS

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605968

Policy instance

Insurance contract or identification number	605968
Number of Individuals Covered	26
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $10,513
Total amount of fees paid to insurance company	USD $1,752
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $210,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,513
Amount paid for insurance broker fees	1752
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0066916

Policy instance

Insurance contract or identification number	W0066916
Number of Individuals Covered	76
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $41,398
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $588,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,628
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-72-48

Policy instance

Insurance contract or identification number	9906-72-48
Number of Individuals Covered	115
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $525
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $300
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	107
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $254
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $5,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $254
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1907100

Policy instance

Insurance contract or identification number	1907100
Number of Individuals Covered	1
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116724

Policy instance

Insurance contract or identification number	10116724
Number of Individuals Covered	116
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $10,550
Total amount of fees paid to insurance company	USD $7,775
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $70,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,550
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	OVERRIDES BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

1D034635

Policy instance

Insurance contract or identification number	1D034635
Number of Individuals Covered	70
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $7,997
Total amount of fees paid to insurance company	USD $8,226
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $79,968
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	6658
Additional information about fees paid to insurance broker	OVERRIDES BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10229820

Policy instance

Insurance contract or identification number	10229820
Number of Individuals Covered	101
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $10,486
Total amount of fees paid to insurance company	USD $4,514
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $104,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,620
Amount paid for insurance broker fees	3708
Additional information about fees paid to insurance broker	CONSULTING FEES
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116722

Policy instance

Insurance contract or identification number	10116722
Number of Individuals Covered	105
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,377
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $55,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,377
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	109
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $258
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $5,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $258
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0805552

Policy instance

Insurance contract or identification number	0805552
Number of Individuals Covered	14
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $7,944
Total amount of fees paid to insurance company	USD $2
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $124,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,674
Amount paid for insurance broker fees	2
Additional information about fees paid to insurance broker	INDIRECT COMPENSATION
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

9906-72-48

Policy instance

Insurance contract or identification number	9906-72-48
Number of Individuals Covered	105
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $225
Total amount of fees paid to insurance company	USD $300
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	300
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0805552HNO

Policy instance

Insurance contract or identification number	0805552HNO
Number of Individuals Covered	80
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $45,531
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $708,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $32,522
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0805552

Policy instance

Insurance contract or identification number	0805552
Number of Individuals Covered	15
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $8,659
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,185
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LEBHERZ INSURANCE SERVICES, INC.

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0805552HNO

Policy instance

Insurance contract or identification number	0805552HNO
Number of Individuals Covered	84
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $47,713
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $686,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,081
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	LEBHERZ INSURANCE SERVICES, INC.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

448431

Policy instance

Insurance contract or identification number	448431
Number of Individuals Covered	108
Insurance policy start date	2017-01-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $1,206
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,206
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	EMMETT W. MACCORKLE, INC.

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099067248

Policy instance

Insurance contract or identification number	000099067248
Number of Individuals Covered	111
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $525
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $300
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116722

Policy instance

Insurance contract or identification number	10116722
Number of Individuals Covered	111
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,679
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $44,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,253
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	RSC INSURANCE BROKERAGE, INC.

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	110
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $260
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $5,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $260
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICES

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99067248

Policy instance

Insurance contract or identification number	99067248
Number of Individuals Covered	107
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $525
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $300
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	105
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $248
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $4,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $248
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

448431

Policy instance

Insurance contract or identification number	448431
Number of Individuals Covered	108
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $4,837
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $123,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,837
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95490 )

Policy contract number

805552HNO

Policy instance

Insurance contract or identification number	805552HNO
Number of Individuals Covered	90
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $45,341
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $649,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,892
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116722

Policy instance

Insurance contract or identification number	10116722
Number of Individuals Covered	107
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $7,282
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $48,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,282
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

805552

Policy instance

Insurance contract or identification number	805552
Number of Individuals Covered	13
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $7,339
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,718
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099067248

Policy instance

Insurance contract or identification number	000099067248
Number of Individuals Covered	121
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $525
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $300
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICES

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	102
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $243
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	EAP
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $243
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116723

Policy instance

Insurance contract or identification number	10116723
Number of Individuals Covered	105
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,614
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $17,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,614
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0805552

Policy instance

Insurance contract or identification number	0805552
Number of Individuals Covered	7
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $3,058
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 $45,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,185
Insurance broker organization code?	3
Insurance broker name	LEBHERZ INSURANCE SERVICES INC

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95490 )

Policy contract number

0805552HNO

Policy instance

Insurance contract or identification number	0805552HNO
Number of Individuals Covered	88
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $41,073
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 $585,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,338
Insurance broker organization code?	3
Insurance broker name	LEBHERZ INSURANCE SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 10128

Policy instance

Insurance contract or identification number	400001000 10128
Number of Individuals Covered	16
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $600
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	VOL LIFE; VOL CHILD/SPOUSE LIFE; VOL AD&D; VOL SPOUSE AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $600
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116722

Policy instance

Insurance contract or identification number	10116722
Number of Individuals Covered	105
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,682
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,682
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116724

Policy instance

Insurance contract or identification number	10116724
Number of Individuals Covered	105
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $926
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	WEEKLY INCOME
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,174
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
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00448431

Policy instance

Insurance contract or identification number	00448431
Number of Individuals Covered	107
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,712
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	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 $118,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,712
Insurance broker organization code?	3
Insurance broker name	EMMETT W MACCORKLE INC INS SER

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116722

Policy instance

Insurance contract or identification number	10116722
Number of Individuals Covered	99
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,522
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,522
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116724

Policy instance

Insurance contract or identification number	10116724
Number of Individuals Covered	99
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $801
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	WEEKLY INCOME
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $801
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00448431

Policy instance

Insurance contract or identification number	00448431
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 $4,813
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	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 $121,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,813
Insurance broker organization code?	3
Insurance broker name	EMMETT W MACCORKLE INC INS SER

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	102
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $242
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	EAP
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $242
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICES

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099067248

Policy instance

Insurance contract or identification number	000099067248
Number of Individuals Covered	122
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $450
Total amount of fees paid to insurance company	USD $23
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $225
Amount paid for insurance broker fees	23
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116723

Policy instance

Insurance contract or identification number	10116723
Number of Individuals Covered	99
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,504
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,504
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0805552

Policy instance

Insurance contract or identification number	0805552
Number of Individuals Covered	13
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $5,943
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 $84,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,245
Insurance broker organization code?	3
Insurance broker name	LEBHERZ INSURANCE SERVICES INC

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95003 )

Policy contract number

US406900

Policy instance

Insurance contract or identification number	US406900
Number of Individuals Covered	154
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $37,705
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 $593,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,932
Insurance broker organization code?	3
Insurance broker name	LEBHERZ INSURANCE SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 10128

Policy instance

Insurance contract or identification number	400001000 10128
Number of Individuals Covered	16
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $461
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	VOL LIFE; VOL CHILD/SPOUSE LIFE; VOL AD&D; VOL SPOUSE AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $461
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116724

Policy instance

Insurance contract or identification number	10116724
Number of Individuals Covered	100
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $799
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	WEEKLY INCOME
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $799
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00448431

Policy instance

Insurance contract or identification number	00448431
Number of Individuals Covered	101
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,378
Total amount of fees paid to insurance company	USD $1,891
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	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 $102,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,357
Amount paid for insurance broker fees	1891
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	WILLNER-CARDINET-KIDWELL

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400001000 10128

Policy instance

Insurance contract or identification number	400001000 10128
Number of Individuals Covered	15
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $451
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	VOL LIFE; VOL CHILD/SPOUSE LIFE; VOL AD&D; VOL SPOUSE AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $451
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95003 )

Policy contract number

US406900

Policy instance

Insurance contract or identification number	US406900
Number of Individuals Covered	154
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $36,141
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 $517,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,815
Insurance broker organization code?	3
Insurance broker name	LEBHERZ INSURANCE SERVICES INC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

805552

Policy instance

Insurance contract or identification number	805552
Number of Individuals Covered	5
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $3,039
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 $46,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,171
Insurance broker organization code?	3
Insurance broker name	LEBHERZ INSURANCE SERVICES INC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116723

Policy instance

Insurance contract or identification number	10116723
Number of Individuals Covered	101
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,502
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $16,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,502
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099067248

Policy instance

Insurance contract or identification number	000099067248
Number of Individuals Covered	109
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $450
Total amount of fees paid to insurance company	USD $26
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	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $225
Amount paid for insurance broker fees	26
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICES

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10116722

Policy instance

Insurance contract or identification number	10116722
Number of Individuals Covered	101
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,525
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,525
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICE

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )

Policy contract number

14741

Policy instance

Insurance contract or identification number	14741
Number of Individuals Covered	94
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $239
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	EAP
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $4,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $239
Insurance broker organization code?	3
Insurance broker name	MACCORKLE INSURANCE SERVICES

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Company Name:	THE POLICE CREDIT UNION OF CALIFORNIA
Employer identification number (EIN):	941278209
NAIC Classification:	522130
NAIC Description:	Credit Unions