401k Plan data: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN plan

CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	CURTCO ROBB MEDIA WELFARE BENEFITS PLAN
Plan identification number	501

CURTCO ROBB MEDIA WELFARE BENEFITS PLAN Benefits

401k Plan Type

Welfare Benefit

Plan Features/Benefits

Health (other than dental or vision)
Life insurance
Dental
Vision
Temporary disability (accident and sickness)
Long-term disability cover
Death benefits (include travel accident but not life insurance)
Other welfare benefit cover
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

CURTCO ROBB MEDIA, LLC. has sponsored the creation of one or more 401k plans.

Company Name: CURTCO ROBB MEDIA, LLC.

Employer identification number (EIN): 954863977

NAIC Classification: 511120
NAIC Description: Periodical Publishers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CURTCO ROBB MEDIA WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-07-01 MELINDA LYON
501 2014-07-01 MELINDA LYON
501 2013-07-01 MELINDA LYON
501 2010-07-01 MELINDA LYON

Plan id#	Filing Submission Date	Name of Administrator
501	2015-07-01	MELINDA LYON
501	2014-07-01	MELINDA LYON
501	2013-07-01	MELINDA LYON
501	2010-07-01	MELINDA LYON

Plan Statistics for CURTCO ROBB MEDIA WELFARE BENEFITS PLAN

401k plan membership statisitcs for CURTCO ROBB MEDIA WELFARE BENEFITS PLAN

Measure Date Value
2015: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-07-01 117
Total number of active participants reported on line 7a of the Form 5500 2015-07-01 101
Number of retired or separated participants receiving benefits 2015-07-01 4
Number of other retired or separated participants entitled to future benefits 2015-07-01 0
Total of all active and inactive participants 2015-07-01 105
2014: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-07-01 102
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 116
Number of retired or separated participants receiving benefits 2014-07-01 1
Number of other retired or separated participants entitled to future benefits 2014-07-01 0
Total of all active and inactive participants 2014-07-01 117
2013: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-07-01 100
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 100
Number of retired or separated participants receiving benefits 2013-07-01 2
Number of other retired or separated participants entitled to future benefits 2013-07-01 0
Total of all active and inactive participants 2013-07-01 102
2010: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-07-01 161
Total number of active participants reported on line 7a of the Form 5500 2010-07-01 81
Number of retired or separated participants receiving benefits 2010-07-01 0
Number of other retired or separated participants entitled to future benefits 2010-07-01 0
Total of all active and inactive participants 2010-07-01 81

Measure	Date	Value
2015: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	117
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	101
Number of retired or separated participants receiving benefits	2015-07-01	4
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	105
2014: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	102
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	116
Number of retired or separated participants receiving benefits	2014-07-01	1
Number of other retired or separated participants entitled to future benefits	2014-07-01	0
Total of all active and inactive participants	2014-07-01	117
2013: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	100
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	100
Number of retired or separated participants receiving benefits	2013-07-01	2
Number of other retired or separated participants entitled to future benefits	2013-07-01	0
Total of all active and inactive participants	2013-07-01	102
2010: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	161
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	81
Number of retired or separated participants receiving benefits	2010-07-01	0
Number of other retired or separated participants entitled to future benefits	2010-07-01	0
Total of all active and inactive participants	2010-07-01	81

Form 5500 Responses for CURTCO ROBB MEDIA WELFARE BENEFITS PLAN

2015: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Submission has been amended	No
2015-07-01	This submission is the final filing	No
2015-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-07-01	Plan is a collectively bargained plan	No
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2014: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Submission has been amended	No
2014-07-01	This submission is the final filing	No
2014-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-07-01	Plan is a collectively bargained plan	No
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2013: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Submission has been amended	No
2013-07-01	This submission is the final filing	No
2013-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-07-01	Plan is a collectively bargained plan	No
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2010: CURTCO ROBB MEDIA WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Submission has been amended	No
2010-07-01	This submission is the final filing	No
2010-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-07-01	Plan is a collectively bargained plan	No
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GLTD0AJ9Q

Policy instance

Insurance contract or identification number	GLTD0AJ9Q
Number of Individuals Covered	101
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $3,799
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	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 $18,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,799
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

902294

Policy instance

Insurance contract or identification number	902294
Number of Individuals Covered	96
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $7,459
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	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 $74,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,459
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

W0051720

Policy instance

Insurance contract or identification number	W0051720
Number of Individuals Covered	81
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $23,746
Total amount of fees paid to insurance company	USD $1,854
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 $791,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,746
Amount paid for insurance broker fees	1854
Additional information about fees paid to insurance broker	BONUS OVERRIDE ALLOCATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30030222

Policy instance

Insurance contract or identification number	30030222
Number of Individuals Covered	85
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $842
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $842
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GUG 0AJ9Q

Policy instance

Insurance contract or identification number	GUG 0AJ9Q
Number of Individuals Covered	45
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,262
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,262
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GLUG0AJ9Q

Policy instance

Insurance contract or identification number	GLUG0AJ9Q
Number of Individuals Covered	101
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $882
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $882
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GVTL0AJ9Q

Policy instance

Insurance contract or identification number	GVTL0AJ9Q
Number of Individuals Covered	29
Insurance policy start date	2015-07-01
Insurance policy end date	2016-06-30
Total amount of commissions paid to insurance broker	USD $1,316
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,316
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

970820/970819

Policy instance

Insurance contract or identification number	970820/970819
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 $18,859
Total amount of fees paid to insurance company	USD $4,960
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 $628,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,859
Amount paid for insurance broker fees	4960
Additional information about fees paid to insurance broker	BONUS OVERRIDE ALLOCATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GLUG0AJ9Q

Policy instance

Insurance contract or identification number	GLUG0AJ9Q
Number of Individuals Covered	116
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $845
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $845
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30030222

Policy instance

Insurance contract or identification number	30030222
Number of Individuals Covered	94
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $819
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $819
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GLTD0AJ9Q

Policy instance

Insurance contract or identification number	GLTD0AJ9Q
Number of Individuals Covered	116
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $3,498
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 $17,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,498
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

902294

Policy instance

Insurance contract or identification number	902294
Number of Individuals Covered	84
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $6,570
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	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 $66,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,569
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GUG 0AJ9Q

Policy instance

Insurance contract or identification number	GUG 0AJ9Q
Number of Individuals Covered	58
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,172
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,172
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GVTL0AJ9Q

Policy instance

Insurance contract or identification number	GVTL0AJ9Q
Number of Individuals Covered	31
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $1,062
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,062
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30030222

Policy instance

Insurance contract or identification number	30030222
Number of Individuals Covered	84
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $775
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $427
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GLUG0AJ9Q

Policy instance

Insurance contract or identification number	GLUG0AJ9Q
Number of Individuals Covered	100
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $770
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $387
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE SVCS.

UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

354316

Policy instance

Insurance contract or identification number	354316
Number of Individuals Covered	11
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,910
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 $96,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,872
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GLTD0AJ9Q

Policy instance

Insurance contract or identification number	GLTD0AJ9Q
Number of Individuals Covered	100
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $3,181
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 $15,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,600
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

607934

Policy instance

Insurance contract or identification number	607934
Number of Individuals Covered	105
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $17,246
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 $574,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,266
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

902294

Policy instance

Insurance contract or identification number	902294
Number of Individuals Covered	75
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $5,646
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	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 $61,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,646
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE SVCS.

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

Policy contract number

GUG 0AJ9Q

Policy instance

Insurance contract or identification number	GUG 0AJ9Q
Number of Individuals Covered	45
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $1,039
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	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $5,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $530
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVCS.

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

Policy contract number

GVTL0AJ9Q

Policy instance

Insurance contract or identification number	GVTL0AJ9Q
Number of Individuals Covered	27
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $872
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $5,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $436
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE SVCS.

MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

CCML0001

Policy instance

Insurance contract or identification number	CCML0001
Number of Individuals Covered	81
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $202
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

688308G

Policy instance

Insurance contract or identification number	688308G
Number of Individuals Covered	81
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $3,038
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

00458840

Policy instance

Insurance contract or identification number	00458840
Number of Individuals Covered	67
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $3,387
Total amount of fees paid to insurance company	USD $724
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 $63,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

N5828/N5369

Policy instance

Insurance contract or identification number	N5828/N5369
Number of Individuals Covered	51
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $11,134
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 $372,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CURTCO ROBB MEDIA, LLC.
Employer identification number (EIN):	954863977
NAIC Classification:	511120
NAIC Description:	Periodical Publishers