Annual Return/Report of Employee Benefit Plan

Transcription

1 Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Annual Return/Report of Employee Benefit Plan This form is required to be filed for employee benefit plans under sections 04 and 4065 of the Employee Retirement Income Security Act of 974 (ERISA) and sections 6047(e), 6057(b), and 6058(a) of the Internal Revenue Code (the Code). Complete all entries in accordance with the instructions to the Form Part I Annual Report Identification Information For calendar plan year 20 or fiscal plan year beginning 0/0/20 and ending 2//20 A This return/report is for: X a multiemployer plan; X a multiple-employer plan; or X a single-employer plan; X a DFE (specify) _C_ B This return/report is: X the first return/report; X the final return/report; X an amended return/report; X a short plan year return/report (less than 2 months). OMB Nos This Form is Open to Public Inspection C If the plan is a collectively-bargained plan, check here X D Check box if filing under: X Form 5558; X automatic extension; X the DFVC program; X special extension (enter description) ABCDE Part II Basic Plan Information enter all requested information a Name of plan ABCDEFGHI COLUMBIA ABCDEFGHI COLLEGE EMPLOYEE ABCDEFGHI BENEFITS ABCDEFGHI PLAN ABCDEFGHI 2a Plan sponsor s name and address, including room or suite number (Employer, if for single-employer plan) COLUMBIA COLLEGE ABCDEFGHI D/B/A ABCDEFGHI c/o ABCDEFGHI 00 ROGERS ST CITYEFGHI COLUMBIAABCDEFGHI AB, MO ST UK b Three-digit plan number (PN) c Effective date of plan 07/0/974 YYYY-MM-DD 2b Employer Identification Number (EIN) c Sponsor s telephone number d Business (see instructions) Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established. Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules, statements and attachments, as well as the electronic version of this return/report, and to the best of my knowledge and belief, it is true, correct, and complete. SIGN HERE 09/25/202 YYYY-MM-DD Bruce ABCDEFGHI BoyerABCDEFGHI ABCDEFGHI ABCDE Signature of plan administrator Date Enter name of individual signing as plan administrator SIGN HERE YYYY-MM-DD ABCDE Signature of employer/plan sponsor Date Enter name of individual signing as employer or plan sponsor SIGN YYYY-MM-DD ABCDE HERE Signature of DFE Date Enter name of individual signing as DFE For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form Form 5500 (20) v.026

2 Form 5500 (20) Page 2 a Plan administrator s name and address (if same as plan sponsor, enter Same ) b Administrator s EIN ABCDEFGHI COLUMBIA ABCDEFGHI COLLEGE ABCDEFGHI ABCDEFGHI c/o ABCDEFGHI c Administrator s telephone ROGERS ABCDEFGHI ST ABCDEFGHI ABCDE number CITYEFGHI COLUMBIA ABCDEFGHI AB, ST MO UK If the name and/or EIN of the plan sponsor has changed since the last return/report filed for this plan, enter the name, EIN and 4b EIN the plan number from the last return/report: a Sponsor s name ABCDEFGHI 4c PN 02 5 Total number of participants at the beginning of the plan year Number of participants as of the end of the plan year (welfare plans complete only lines 6a, 6b, 6c, and 6d). a Active participants... 6a b Retired or separated participants receiving benefits... 6b c Other retired or separated participants entitled to future benefits... 6c d Subtotal. Add lines 6a, 6b, and 6c... 6d e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits.... 6e f Total. Add lines 6d and 6e.... 6f g Number of participants with account balances as of the end of the plan year (only defined contribution plans complete this item)... 6g h Number of participants that terminated employment during the plan year with accrued benefits that were less than 00% vested... 6h Enter the total number of employers obligated to contribute to the plan (only multiemployer plans complete this item) a If the plan provides pension benefits, enter the applicable pension feature s from the List of Plan Characteristic Codes in the instructions: b If the plan provides welfare benefits, enter the applicable welfare feature s from the List of Plan Characteristic Codes in the instructions: 4A 4B 4D 4E 4F 4H 4Q 9a Plan funding arrangement (check all that apply) 9b Plan benefit arrangement (check all that apply) () X Insurance () X Insurance (2) X Code section 42(e)() insurance contracts (2) X Code section 42(e)() insurance contracts () X Trust () X Trust (4) X General assets of the sponsor (4) X General assets of the sponsor 0 Check all applicable boxes in 0a and 0b to indicate which schedules are attached, and, where indicated, enter the number attached. (See instructions) a Pension Schedules () X R (Retirement Plan Information) (2) X MB (Multiemployer Defined Benefit Plan and Certain Money Purchase Plan Actuarial Information) - signed by the plan actuary () X SB (Single-Employer Defined Benefit Plan Actuarial Information) - signed by the plan actuary b General Schedules () X H (Financial Information) (2) X I (Financial Information Small Plan) () X A (Insurance Information) (4) X C (Service Provider Information) (5) X D (DFE/Participating Plan Information) (6) X G (Financial Transaction Schedules)

3 SCHEDULE A (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Insurance Information This schedule is required to be filed under section 04 of the Employee Retirement Income Security Act of 974 (ERISA). File as an attachment to Form Insurance companies are required to provide the information pursuant to ERISA section 0(a)(2). OMB No This Form is Open to Public Inspection For calendar plan year 20 or fiscal plan year beginning 0/0/20 and ending 2//20 A Name of plan B Three-digit ABCDEFGHI COLUMBIA ABCDEFGHI COLLEGE EMPLOYEE ABCDEFGHI BENEFITS ABCDEFGHI PLANABCDEFGHI ABCDE plan number (PN) FGHI ABCDEFGHI ABCDEFGHI C Plan sponsor s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN) ABCDEFGHI ABCDEFGHI ABCDE FGHI COLUMBIA ABCDEFGHI COLLEGE Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A. Coverage Information: (a) Name of insurance carrier ABCDEFGHI UNITEDHEALTHCARE INSURANCE COMPANY (b) EIN (c) NAIC (d) Contract or identification number (e) Approximate number of persons covered at end of policy or contract year (f) From Policy or contract year ABCDE 794 ABCDE YYYY-MM-DD 0/0/20 YYYY-MM-DD 2//20 2 Insurance fee and commission information. Enter the total fees and total. List in item the agents, brokers, and other persons in descending order of the amount paid. (a) Total amount of (g) To (b) Total amount of fees paid Persons receiving commissions and fees. (Complete as many entries as needed to report all persons). ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form Schedule A (Form 5500) 20 v.026

4 Schedule A (Form 5500) 20 Page 2 - x ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE

5 Schedule A (Form 5500) 20 Page Part II Investment and Annuity Contract Information Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 4 Current value of plan s interest under this contract in the general account at year end Current value of plan s interest under this contract in separate accounts at year end Contracts With Allocated Funds: a State the basis of premium rates b Premiums paid to carrier... 6b c Premiums due but unpaid at the end of the year... 6c d 6d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, enter amount.... Specify nature of costs e Type of contract: () X individual policies (2) X group deferred annuity () X other (specify) f If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here X 7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract: () X deposit administration (2) X immediate participation guarantee () X guaranteed investment (4) X other b Balance at the end of the previous year... 7b c Additions: () Contributions deposited during the year... 7c() (2) Dividends and credits... 7c(2) () Interest credited during the year... 7c() (4) Transferred from separate account... 7c(4) (5) Other (specify below)... 7c(5) (6)Total additions... 7c(6) d Total of balance and additions (add b and c(6)).... 7d e Deductions: () Disbursed from fund to pay benefits or purchase annuities during year 7e() (2) Administration charge made by carrier... 7e(2) () Transferred to separate account... 7e() (4) Other (specify below)... 7e(4) (5) Total deductions... 7e(5) f Balance at the end of the current year (subtract e(5) from d)... 7f

6 Schedule A (Form 5500) 20 Page 4 Part III Welfare Benefit Contract Information If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 8 Benefit and contract type (check all applicable boxes) a X Health (other than dental or vision) b X Dental c X Vision d X Life insurance e X Temporary disability (accident and sickness) f X Long-term disability g X Supplemental unemployment h X Prescription drug i X Stop loss (large deductible) j X HMO contract k X PPO contract l X Indemnity contract m X Other (specify) ABCDEFGHI ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 9 Experience-rated contracts: a Premiums: () Amount received... 9a() (2) Increase (decrease) in amount due but unpaid... 9a(2) () Increase (decrease) in unearned premium reserve... 9a() (4) Earned (() + (2) - ())... 9a(4) b Benefit charges () Claims paid... 9b() (2) Increase (decrease) in claim reserves... 9b(2) () Incurred claims (add () and (2))... 9b() (4) Claims charged... 9b(4) c Remainder of premium: () Retention charges (on an accrual basis) (A) Commissions... 9c()(A) (B) Administrative service or other fees... 9c()(B) (C) Other specific acquisition costs... 9c()(C) (D) Other expenses... 9c()(D) (E) Taxes... 9c()(E) (F) Charges for risks or other contingencies... 9c()(F) (G) Other retention charges... 9c()(G) (H) Total retention... 9c()(H) (2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.)... 9c(2) d Status of policyholder reserves at end of year: () Amount held to provide benefits after retirement... 9d() (2) Claim reserves... 9d(2) () Other reserves... 9d() e Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).)... 9e Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier... 0a b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, other than reported in Part I, item 2 above, report amount.... 0b Specify nature of costs Part IV Provision of Information Did the insurance company fail to provide any information necessary to complete Schedule A?... X Yes X No 2 If the answer to line is Yes, specify the information not provided. ABCDEFGHI ABCDE

7 SCHEDULE A (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Insurance Information This schedule is required to be filed under section 04 of the Employee Retirement Income Security Act of 974 (ERISA). File as an attachment to Form Insurance companies are required to provide the information pursuant to ERISA section 0(a)(2). OMB No This Form is Open to Public Inspection For calendar plan year 20 or fiscal plan year beginning 0/0/20 and ending 2//20 A Name of plan B Three-digit ABCDEFGHI COLUMBIA ABCDEFGHI COLLEGE EMPLOYEE ABCDEFGHI BENEFITS ABCDEFGHI PLANABCDEFGHI ABCDE plan number (PN) FGHI ABCDEFGHI ABCDEFGHI C Plan sponsor s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN) ABCDEFGHI ABCDEFGHI ABCDE FGHI COLUMBIA ABCDEFGHI COLLEGE Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A. Coverage Information: (a) Name of insurance carrier ABCDEFGHI THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (b) EIN (c) NAIC (d) Contract or identification number (e) Approximate number of persons covered at end of policy or contract year (f) From Policy or contract year ABCDE ABCDE YYYY-MM-DD 0/0/20 YYYY-MM-DD 06/0/20 2 Insurance fee and commission information. Enter the total fees and total. List in item the agents, brokers, and other persons in descending order of the amount paid. (a) Total amount of (b) Total amount of fees paid (g) To Persons receiving commissions and fees. (Complete as many entries as needed to report all persons). THE ABCDEFGHI INSURANCE ABCDEFGHI GROUP INC ABCDEFGHI ABCDE E SOUTHAMPTON ABCDEFGHI DR ABCDEFGHI ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form Schedule A (Form 5500) 20 v.026

8 Schedule A (Form 5500) 20 Page 2 - x ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE

9 Schedule A (Form 5500) 20 Page Part II Investment and Annuity Contract Information Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 4 Current value of plan s interest under this contract in the general account at year end Current value of plan s interest under this contract in separate accounts at year end Contracts With Allocated Funds: a State the basis of premium rates b Premiums paid to carrier... 6b c Premiums due but unpaid at the end of the year... 6c d 6d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, enter amount.... Specify nature of costs e Type of contract: () X individual policies (2) X group deferred annuity () X other (specify) f If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here X 7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract: () X deposit administration (2) X immediate participation guarantee () X guaranteed investment (4) X other b Balance at the end of the previous year... 7b c Additions: () Contributions deposited during the year... 7c() (2) Dividends and credits... 7c(2) () Interest credited during the year... 7c() (4) Transferred from separate account... 7c(4) (5) Other (specify below)... 7c(5) (6)Total additions... 7c(6) d Total of balance and additions (add b and c(6)).... 7d e Deductions: () Disbursed from fund to pay benefits or purchase annuities during year 7e() (2) Administration charge made by carrier... 7e(2) () Transferred to separate account... 7e() (4) Other (specify below)... 7e(4) (5) Total deductions... 7e(5) f Balance at the end of the current year (subtract e(5) from d)... 7f

10 Part III Schedule A (Form 5500) 20 Page 4 Welfare Benefit Contract Information If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 8 Benefit and contract type (check all applicable boxes) a X Health (other than dental or vision) b X Dental c X Vision d X Life insurance e X Temporary disability (accident and sickness) f X Long-term disability g X Supplemental unemployment h X Prescription drug i X Stop loss (large deductible) j X HMO contract k X PPO contract l X Indemnity contract m X Other (specify) AD&D, ABCDEFGHI VOLUNTARY ABCDEFGHI LIFE & ABCDEFGHI DEPENDENT ABCDEFGHI LIFE, VOLUNTARY ABCDEFGHI AD&D ABCDEFGHI & DEPENDENT ABCDEFGHI AD&D ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 9 Experience-rated contracts: a Premiums: () Amount received... 9a() (2) Increase (decrease) in amount due but unpaid... 9a(2) () Increase (decrease) in unearned premium reserve... 9a() (4) Earned (() + (2) - ())... 9a(4) b Benefit charges () Claims paid... 9b() (2) Increase (decrease) in claim reserves... 9b(2) () Incurred claims (add () and (2))... 9b() (4) Claims charged... 9b(4) c Remainder of premium: () Retention charges (on an accrual basis) (A) Commissions... 9c()(A) (B) Administrative service or other fees... 9c()(B) (C) Other specific acquisition costs... 9c()(C) (D) Other expenses... 9c()(D) (E) Taxes... 9c()(E) (F) Charges for risks or other contingencies... 9c()(F) (G) Other retention charges... 9c()(G) (H) Total retention... 9c()(H) (2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.)... 9c(2) d Status of policyholder reserves at end of year: () Amount held to provide benefits after retirement... 9d() (2) Claim reserves... 9d(2) () Other reserves... 9d() e Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).)... 9e Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier... 0a b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, other than reported in Part I, item 2 above, report amount.... 0b Specify nature of costs Part IV Provision of Information Did the insurance company fail to provide any information necessary to complete Schedule A?... X Yes X No 2 If the answer to line is Yes, specify the information not provided. ABCDEFGHI ABCDE

11 SCHEDULE A (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Insurance Information This schedule is required to be filed under section 04 of the Employee Retirement Income Security Act of 974 (ERISA). File as an attachment to Form Insurance companies are required to provide the information pursuant to ERISA section 0(a)(2). OMB No This Form is Open to Public Inspection For calendar plan year 20 or fiscal plan year beginning 0/0/20 and ending 2//20 A Name of plan B Three-digit ABCDEFGHI COLUMBIA ABCDEFGHI COLLEGE EMPLOYEE ABCDEFGHI BENEFITS ABCDEFGHI PLANABCDEFGHI ABCDE plan number (PN) FGHI ABCDEFGHI ABCDEFGHI C Plan sponsor s name as shown on line 2a of Form 5500 D Employer Identification Number (EIN) ABCDEFGHI ABCDEFGHI ABCDE FGHI COLUMBIA ABCDEFGHI COLLEGE Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A. Coverage Information: (a) Name of insurance carrier ABCDEFGHI AFLAC (b) EIN (c) NAIC (d) Contract or identification number (e) Approximate number of persons covered at end of policy or contract year (f) From Policy or contract year ABCDE 6080 ABCDE BMP YYYY-MM-DD 04/0/200 YYYY-MM-DD 0//20 2 Insurance fee and commission information. Enter the total fees and total. List in item the agents, brokers, and other persons in descending order of the amount paid. (a) Total amount of (b) Total amount of fees paid (g) To Persons receiving commissions and fees. (Complete as many entries as needed to report all persons). BRIAN ABCDEFGHI D NEUNER ABCDEFGHI ABCDEFGHI ABCDE E HIGHWAY ABCDEFGHI WW ABCDEFGHI ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST FEES ABCDE KELLY ABCDEFGHI THOMAS ABCDEFGHI ABCDEFGHI ABCDE OLD BASS ABCDEFGHI ROAD ABCDEFGHI ABCDE EUGENE CITY56789 ABCDEFGHI AB, MOST FEES ABCDE For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form Schedule A (Form 5500) 20 v.026

12 Schedule A (Form 5500) 20 Page 2 - x JON ABCDEFGHI HARTMANABCDEFGHI ABCDEFGHI ABCDE AMAZON ABCDEFGHI DRIVE ABCDEFGHI ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST FEES ABCDE JEREMY ABCDEFGHI BROCKMAN ABCDEFGHI ABCDEFGHI ABCDE WHITE CHAPEL ABCDEFGHI DRIVE ABCDEFGHI ABCDE O CITY56789 FALLON ABCDEFGHI AB, MOST FEES ABCDE ASHTON ABCDEFGHI CONSULTING ABCDEFGHI INCABCDEFGHI ABCDE CORONA ABCDEFGHI RD SUITE ABCDEFGHI 20 ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST FEES ABCDE BRYAN ABCDEFGHI C SWYERS ABCDEFGHI ABCDEFGHI ABCDE HYDE PARK ABCDEFGHI DR ABCDEFGHI ABCDE JEFFERSON CITY56789 CITY ABCDEFGHI AB, MOST FEES ABCDE BRADLEY ABCDEFGHI K HARRISON ABCDEFGHI ABCDEFGHI ABCDE PRODO DR ABCDEFGHI ABCDEFGHI ABCDE JEFFERSON CITY56789 CITY ABCDEFGHI AB, MOST FEES ABCDE

13 Schedule A (Form 5500) 20 Page 2 - x JANEANE ABCDEFGHI E BROCKMAN ABCDEFGHI ABCDEFGHI ABCDE LEATHERBROOK ABCDEFGHI DR ABCDEFGHI ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST FEES ABCDE LISA ABCDEFGHI B NIELSEN ABCDEFGHI ABCDEFGHI ABCDE PO BOX 9698ABCDEFGHI ABCDEFGHI ABCDE SALT CITY56789 LAKE CITY ABCDEFGHI AB, UTST FEES ABCDE JAY ABCDEFGHI P HIGGINS ABCDEFGHI ABCDEFGHI ABCDE MARSHALL ABCDEFGHI ST ABCDEFGHI ABCDE JEFFERSON CITY56789 CITY ABCDEFGHI AB, MOST FEES ABCDE MICHELE ABCDEFGHI L HIGGINS ABCDEFGHI ABCDEFGHI ABCDE WAYNE ABCDEFGHI AVENUE ABCDEFGHI ABCDE JEFFERSON CITY56789 CITY ABCDEFGHI AB, MOST FEES ABCDE CHRISTINA ABCDEFGHI L ABCDEFGHI MALOVANY ABCDEFGHI ABCDE WOODHILL ABCDEFGHI CT ABCDEFGHI ABCDE ELGIN CITY56789 ABCDEFGHI AB, ILST FEES ABCDE

14 Schedule A (Form 5500) 20 Page 2 - x HEATHER ABCDEFGHI L SPRADLIN ABCDEFGHI ABCDEFGHI ABCDE EAST GREEN ABCDEFGHI MEADOWS ABCDEFGHI APT 08 ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST ABCDE SCOTT ABCDEFGHI J BOGENER ABCDEFGHI ABCDEFGHI ABCDE E GREEN ABCDEFGHI MEADOWS RD ABCDEFGHI APT 0 ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST ABCDE CLARENCE ABCDEFGHI B ABCDEFGHI YOUNG III ABCDEFGHI ABCDE EASTDELL ABCDEFGHI DR ABCDEFGHI ABCDE SANDY CITY56789 ABCDEFGHI AB, UTST FEES ABCDE SCOTT ABCDEFGHI A BEER ABCDEFGHI ABCDEFGHI ABCDE CANYON ABCDEFGHI WOODS CIR ABCDEFGHI APT 205 ABCDE SAN CITY56789 RAMON ABCDEFGHI AB, CAST FEES ABCDE SANDIE ABCDEFGHI D EDWARDS ABCDEFGHI ABCDEFGHI ABCDE W SADY ABCDEFGHI AVE ABCDEFGHI ABCDE VISALIA CITY56789 ABCDEFGHI AB, CAST FEES ABCDE

15 Schedule A (Form 5500) 20 Page 2 - x TRENT ABCDEFGHI J NIELSEN ABCDEFGHI ABCDEFGHI ABCDE FAIR ABCDEFGHI HOPE CIR ABCDEFGHI ABCDE HERRIMAN CITY56789 ABCDEFGHI AB, UTST FEES ABCDE MARYANN ABCDEFGHI ENGLE ABCDEFGHI ABCDEFGHI ABCDE S MAIN ABCDEFGHI ST ABCDEFGHI ABCDE COUPEVILLE CITY56789 ABCDEFGHI AB, WAST FEES ABCDE CAROL ABCDEFGHI A MURRAY ABCDEFGHI ABCDEFGHI ABCDE MCKELVEY ABCDEFGHI PLACE ABCDEFGHI ABCDE GOOSE CITY56789 CREEKABCDEFGHI AB, SCST FEES ABCDE SARAH ABCDEFGHI CHIESA ABCDEFGHI ABCDEFGHI ABCDE W RASCHER ABCDEFGHI AVE ABCDEFGHI ABCDE CHICAGO CITY56789 ABCDEFGHI AB, ILST FEES ABCDE DAMON ABCDEFGHI R STREETMAN ABCDEFGHI ABCDEFGHI ABCDE WEST MAPLE ABCDEFGHI LOOP ABCDEFGHI RD SUITE 20 ABCDE LEHI CITY56789 ABCDEFGHI AB, UTST FEES ABCDE

16 Schedule A (Form 5500) 20 Page 2 - x ORLANDO ABCDEFGHI R DOBRINCU ABCDEFGHI ABCDEFGHI ABCDE BURLINGTON ABCDEFGHI DR SUITE ABCDEFGHI 05 ABCDE LISLE CITY56789 ABCDEFGHI AB, ILST FEES ABCDE JACQUELINE ABCDEFGHI ABCDEFGHI D KEELING ABCDEFGHI ABCDE MING AVE ABCDEFGHI SUITE 60 ABCDEFGHI ABCDE BAKERSFILED CITY56789 ABCDEFGHI AB, CAST FEES ABCDE SARAH ABCDEFGHI ELDINABCDEFGHI ABCDEFGHI ABCDE BROOK ABCDEFGHI HILL COURTABCDEFGHI ABCDE CHESTERFIELD CITY56789 ABCDEFGHI AB, MOST ABCDE APRIL ABCDEFGHI L MELVIN ABCDEFGHI ABCDEFGHI ABCDE PO BOX 78 ABCDEFGHI ABCDEFGHI ABCDE ASHLAND CITY56789 ABCDEFGHI AB, MOST ABCDE SHANNON ABCDEFGHI L TROWBRIDGE ABCDEFGHI ABCDEFGHI ABCDE CEMTRAL ABCDEFGHI AVE SUITE ABCDEFGHI 200B ABCDE GOOSE CITY56789 GREEKABCDEFGHI AB, SCST FEES ABCDE

17 Schedule A (Form 5500) 20 Page 2 - x SCOTT ABCDEFGHI T HUNDAHL ABCDEFGHI ABCDEFGHI ABCDE TEAL LN ABCDEFGHI ABCDEFGHI ABCDE BOW CITY56789 ABCDEFGHI AB, WAST FEES ABCDE KAREN ABCDEFGHI LEE LINDSEY ABCDEFGHI ABCDEFGHI ABCDE NOTTINGHAM ABCDEFGHI DR ABCDEFGHI ABCDE SANTA CITY56789 MARIAABCDEFGHI AB, CAST FEES ABCDE TREVE ABCDEFGHI D RASMUSSEN ABCDEFGHI ABCDEFGHI ABCDE W MAIN ABCDEFGHI ST SUITE ABCDEFGHI E ABCDE VISALIA CITY56789 ABCDEFGHI AB, CAST FEES ABCDE HH ABCDEFGHI ASSOCIATES ABCDEFGHI LLC ABCDEFGHI ABCDE PRODO DR ABCDEFGHI ABCDEFGHI ABCDE JEFFERSON CITY56789 CITY ABCDEFGHI AB, MOST ABCDE MICHAEL ABCDEFGHI A ORTIZ ABCDEFGHI ABCDEFGHI ABCDE VOLTAIRE ABCDEFGHI LANE ABCDEFGHI ABCDE ST CITY56789 CHARLES ABCDEFGHI AB, ILST FEES ABCDE

18 Schedule A (Form 5500) 20 Page 2 - x BARRY ABCDEFGHI G WIEBE ABCDEFGHI ABCDEFGHI ABCDE NORTHSHORE ABCDEFGHI DRIVEABCDEFGHI ABCDE BELLINGHAM CITY56789 ABCDEFGHI AB, WAST FEES ABCDE ROBERT ABCDEFGHI I BARNES ABCDEFGHI ABCDEFGHI ABCDE POPLAR ABCDEFGHI AVE SUITE ABCDEFGHI 540 ABCDE MT CITY56789 PLEASANTABCDEFGHI AB, SCST FEES ABCDE ARTHUR ABCDEFGHI COLEGROVE ABCDEFGHI ABCDEFGHI ABCDE E MAIN ABCDEFGHI ABCDEFGHI ABCDE SOUTH CITY56789 ELGINABCDEFGHI AB, ILST FEES ABCDE CHARLES ABCDEFGHI H WEISSBERGER ABCDEFGHI ABCDEFGHI ABCDE OGLETHORPE ABCDEFGHI PROFESSIONAL ABCDEFGHI SUITE ABCDE 202 SAVANNAH CITY56789 ABCDEFGHI AB, GAST FEES ABCDE CHARLES ABCDEFGHI EWARD ABCDEFGHI PERRY ABCDEFGHI ABCDE MING AVE ABCDEFGHI SUITE 250 ABCDEFGHI ABCDE BAKERSFIELD CITY56789 ABCDEFGHI AB, CAST FEES ABCDE

19 Schedule A (Form 5500) 20 Page 2 - x VICTOR ABCDEFGHI P SCHUTZ ABCDEFGHI III ABCDEFGHI ABCDE CANAL ST ABCDEFGHI SUITE 602 ABCDEFGHI ABCDE POOLER CITY56789 ABCDEFGHI AB, GAST FEES ABCDE D ABCDEFGHI BREDESON ABCDEFGHI INSURANCE ABCDEFGHI SERVICES ABCDE HIGUERA ABCDEFGHI ST SUITE ABCDEFGHI 00 ABCDE SAN CITY56789 LUIS OBISPO ABCDEFGHI AB, CAST FEES ABCDE SCOTT ABCDEFGHI W BLACKSHEAR ABCDEFGHI ABCDEFGHI ABCDE FAIRWAY ABCDEFGHI DRIVE EAST ABCDEFGHI ABCDE HIDEAWAY CITY56789 ABCDEFGHI AB, TXST FEES ABCDE C ABCDEFGHI HARVEY KING ABCDEFGHI ABCDEFGHI ABCDE PO BOX ABCDEFGHI ABCDEFGHI ABCDE WEST CITY56789 JEFFERSON ABCDEFGHI AB, NCST FEES ABCDE WILLIAM ABCDEFGHI L AMOS ABCDEFGHI & CO INC ABCDEFGHI ABCDE RIVER ABCDEFGHI RD SUITE 205 ABCDEFGHI ABCDE COLUMBUS CITY56789 ABCDEFGHI AB, GAST FEES ABCDE

20 Schedule A (Form 5500) 20 Page 2 - x JODI ABCDEFGHI L DAVIS ABCDEFGHI ABCDEFGHI ABCDE E MAIN ABCDEFGHI ST ABCDEFGHI ABCDE SOUTH CITY56789 ELGINABCDEFGHI AB, ILST FEES ABCDE KATHY ABCDEFGHI Y ESTES ABCDEFGHI ABCDEFGHI ABCDE PO BOX 7222ABCDEFGHI ABCDEFGHI ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST ABCDE JEFFEREY ABCDEFGHI M ABCDEFGHI SATTERLEE ABCDEFGHI ABCDE S PECOS ABCDEFGHI AVE ABCDEFGHI ABCDE COLUMBIA CITY56789 ABCDEFGHI AB, MOST ABCDE LOUIS ABCDEFGHI CULLEN ABCDEFGHI SMITH ABCDEFGHI ABCDE BELTLINE ABCDEFGHI RD SW SUITE ABCDEFGHI A 5ABCDE DECATUR CITY56789 ABCDEFGHI AB, ALST FEES ABCDE R ABCDEFGHI AND L SUPPLEMENTAL ABCDEFGHI ABCDEFGHI BENEFITS INC ABCDE PO BOX 89 ABCDEFGHI ABCDEFGHI ABCDE FLORENCE CITY56789 ABCDEFGHI AB, ALST FEES ABCDE

21 Schedule A (Form 5500) 20 Page 2 - x SAIC ABCDEFGHI INC ABCDEFGHI ABCDEFGHI ABCDE MILGEN ABCDEFGHI ROAD ABCDEFGHI ABCDE COLUMBUS CITY56789 ABCDEFGHI AB, GAST FEES ABCDE STEVE ABCDEFGHI C BRANNON ABCDEFGHI ABCDEFGHI ABCDE BURNINGTEE ABCDEFGHI MTN RD ABCDEFGHI SE ABCDE DECATUR CITY56789 ABCDEFGHI AB, ALST FEES ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE ABCDE CITY56789 ABCDEFGHI AB, ST ABCDE

22 Schedule A (Form 5500) 20 Page Part II Investment and Annuity Contract Information Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 4 Current value of plan s interest under this contract in the general account at year end Current value of plan s interest under this contract in separate accounts at year end Contracts With Allocated Funds: a State the basis of premium rates b Premiums paid to carrier... 6b c Premiums due but unpaid at the end of the year... 6c d 6d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, enter amount.... Specify nature of costs e Type of contract: () X individual policies (2) X group deferred annuity () X other (specify) f If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here X 7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract: () X deposit administration (2) X immediate participation guarantee () X guaranteed investment (4) X other b Balance at the end of the previous year... 7b c Additions: () Contributions deposited during the year... 7c() (2) Dividends and credits... 7c(2) () Interest credited during the year... 7c() (4) Transferred from separate account... 7c(4) (5) Other (specify below)... 7c(5) (6)Total additions... 7c(6) d Total of balance and additions (add b and c(6)).... 7d e Deductions: () Disbursed from fund to pay benefits or purchase annuities during year 7e() (2) Administration charge made by carrier... 7e(2) () Transferred to separate account... 7e() (4) Other (specify below)... 7e(4) (5) Total deductions... 7e(5) f Balance at the end of the current year (subtract e(5) from d)... 7f

23 Schedule A (Form 5500) 20 Page 4 Part III Welfare Benefit Contract Information If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), the information may be combined for reporting purposes if such contracts are experience-rated as a unit. Where contracts cover individual employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 8 Benefit and contract type (check all applicable boxes) a X Health (other than dental or vision) b X Dental c X Vision d X Life insurance e X Temporary disability (accident and sickness) f X Long-term disability g X Supplemental unemployment h X Prescription drug i X Stop loss (large deductible) j X HMO contract k X PPO contract l X Indemnity contract m X Other (specify) VOLUNTARY ABCDEFGHI ACCIDENT, ABCDEFGHI CANCER ABCDEFGHI ABCDEFGHI ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 9 Experience-rated contracts: a Premiums: () Amount received... 9a() (2) Increase (decrease) in amount due but unpaid... 9a(2) () Increase (decrease) in unearned premium reserve... 9a() (4) Earned (() + (2) - ())... 9a(4) b Benefit charges () Claims paid... 9b() (2) Increase (decrease) in claim reserves... 9b(2) () Incurred claims (add () and (2))... 9b() (4) Claims charged... 9b(4) c Remainder of premium: () Retention charges (on an accrual basis) (A) Commissions... 9c()(A) (B) Administrative service or other fees... 9c()(B) (C) Other specific acquisition costs... 9c()(C) (D) Other expenses... 9c()(D) (E) Taxes... 9c()(E) (F) Charges for risks or other contingencies... 9c()(F) (G) Other retention charges... 9c()(G) (H) Total retention... 9c()(H) (2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.)... 9c(2) d Status of policyholder reserves at end of year: () Amount held to provide benefits after retirement... 9d() (2) Claim reserves... 9d(2) () Other reserves... 9d() e Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).)... 9e Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier... 0a b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, other than reported in Part I, item 2 above, report amount.... 0b Specify nature of costs Part IV Provision of Information Did the insurance company fail to provide any information necessary to complete Schedule A?... X Yes X No 2 If the answer to line is Yes, specify the information not provided. ABCDEFGHI ABCDE