SCHEDULE A                                        Insurance Information                                                    OMB No. 1210-0110 
        (Form 5500) 
        Department of the Treasury          This schedule is required to be filed under section 104 of the 
        Internal Revenue Service            Employee Retirement Income Security Act of 1974 (ERISA).                               2023 
        Department of Labor 
 Employee Benefits Security Administration                 File as an attachment to Form 5500.
    Pension Benefit Guaranty Corporation     Insurance companies are required to provide the information          This Form is Open to Public 
                                                          pursuant to ERISA section 103(a)(2).                                     Inspection 
For calendar plan year 2023 or fiscal plan year beginning                                       and ending         
A  Name of plan                                                                                B    Three-digit
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE                                         plan number (PN)                                      001 
FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI  
ABCDEFGHI ABCDEFGHI ABCDEFGHI  
C  Plan sponsor’s name as shown on line 2a of Form 5500                                        D  Employer Identification Number (EIN)
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE                                         012345678 
FGHI ABCDEFGHI  
 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. 
1  Coverage Information:
(a) Name of insurance carrier
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

        (b) EIN                    (c) NAIC  (d) Contract or       (e)  Approximate number of                      Policy or contract year 
                                   code      identification number     persons covered at end of               (f) From                   (g) To
                                                                        policy or contract year 

012345678                   ABCDE           ABCDE0123456789        1234567                                 YYYY-MM-DD                     YYYY-MM-DD 
2  Insurance fee and commission information. Enter the total fees and total commissions paid.  List in line 3 the agents, brokers, and other persons in
 descending order of the amount paid. 
            (a) Total amount of commissions paid                                                (b) Total amount of fees paid
                                            123456789012345                                                                        123456789012345 
3  Persons receiving commissions and fees.  (Complete as many entries as needed to report all persons).
                                   (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
    (b) Amount of sales and base                                   Fees and other commissions paid 
        commissions paid                    (c) Amount                     (d) Purpose                                             (e) Organization code
    -123456789012345                        -123456789012345       ABCDEFGHI ABCDEFGHI ABCDEFGHI                                              1 
                                                                   ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                                          SAMPLEABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
                                   (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
    (b) Amount of sales and base                                   Fees and other commissions paid 
        commissions paid                    (c) Amount                     (d) Purpose                                             (e) Organization code
    -123456789012345                        -123456789012345       ABCDEFGHI ABCDEFGHI ABCDEFGHI                                              1 
                                                                   ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                                                   ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.                                                  Schedule A (Form 5500) 2023 
                                                                                                                                                       v. 230728

    Schedule A  (Form 5500) 2023              Page 2   – 1  x  

                     (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
    commissions paid             (c) Amount              (d) Purpose                                                  code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
                     (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
    commissions paid             (c) Amount              (d) Purpose                                                  code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
                     (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
    commissions paid             (c) Amount              (d) Purpose                                                  code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE                                     
                     (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
    commissions paid             (c) Amount              (d) Purpose                                                  code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                     SAMPLE
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE                                     
                     (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
    commissions paid             (c) Amount              (d) Purpose                                                  code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 

       Schedule A  (Form 5500) 2023                                                                                Page 3

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 ................................................                                    4     123456789012345 
5  Current value of plan’s interest under this contract in separate accounts at year end ...................................................                                   5     123456789012345 
6  Contracts With Allocated Funds:
   a   State the basis of premium rates 

   b   Premiums paid to carrier .......................................................................................................................................        6b    -123456789012345
   c   Premiums due but unpaid at the end of the year ...................................................................................................                      6c    -123456789012345
   d   If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or                                                        6d    -123456789012345
       retention of the contract or policy, enter amount. ..................................................................................................  
       Specify nature of costs     

   e   Type of contract:   (1)    Xindividual policies       (2)     Xgroup deferred annuity 
       (3)     Xother (specify)    

    f  If contract purchased, in whole or in part, to distribute benefits from a terminating plan, check here              X                                                    X
7  Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
   a   Type of contract:   (1)    Xdeposit administration           (2)    Ximmediate participation guarantee 
                           (3)    Xguaranteed investment            (4)    Xother 

   b   Balance at the end of the previous year ................................................................................................................                7b    123456789012345 
   c   Additions:  (1) Contributions deposited during the year ................................                    7c(1) -123456789012345
       (2) Dividends and credits ...............................................................................   7c(2) -123456789012345
       (3) Interest credited during the year ..............................................................        7c(3) -123456789012345
       (4) Transferred from separate account ..........................................................            7c(4) -123456789012345
       (5) Other (specify below) ...............................................................................   7c(5) -123456789012345
      

       (6)Total additions ...................................................................................................................................................  7c(6) 123456789012345 
    d  Total of balance and additions (add lines 7b and 7c(6)).  .......................................................................................                       7d    123456789012345 
    e  Deductions:
       (1) Disbursed from fund to pay benefits or purchase annuities during year                                   7e(1) -123456789012345
       (2) Administration charge made by carrier .....................................................             7e(2) -123456789012345
       (3) Transferred to separate account ...............................................................         7e(3) -123456789012345
       (4) Other (specify below) ................................................................................  7e(4) -123456789012345
       
                                                      SAMPLE

       (5) Total deductions ................................................................................................................................................   7e(5) 123456789012345 
    f  Balance at the end of the current year (subtract line 7e(5) from line 7d) ..............................................................                                7f    123456789012345 

        Schedule A  (Form 5500) 2023                                                                               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 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
                                      ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
9  Experience-rated contracts: 
   a   Premiums: (1) Amount received .................................................................             9a(1)    -123456789012345
       (2) Increase (decrease) in amount due but unpaid ....................................                       9a(2)    -123456789012345
       (3) Increase (decrease) in unearned premium reserve .............................                           9a(3)    -123456789012345
       (4) Earned ((1)  +(2)  (3) -   ) ...................................................................................................................................................9a(4)    123456789012345 
    b  Benefit charges (1) Claims paid ................................................................            9b(1)    -123456789012345
       (2) Increase (decrease) in claim reserves .................................................                 9b(2)    -123456789012345
       (3) Incurred claims (add       (1) and (2)) ...................................................................................................................    9b(3)                     123456789012345 
       (4) Claims charged .............................................................................................................................................   9b(4)                     123456789012345 
    c  Remainder of premium: (1) Retention charges (on an accrual basis) --                                                 -123456789012345
           (A) Commissions ................................................................................        9c(1)(A) -123456789012345
           (B) Administrative service or other fees ..............................................                 9c(1)(B) -123456789012345
           (C) Other specific acquisition costs ....................................................               9c(1)(C) -123456789012345
           (D) Other expenses ............................................................................         9c(1)(D) -123456789012345
           (E) Taxes ............................................................................................  9c(1)(E) -123456789012345
           (F) Charges for risks or other contingencies .......................................                    9c(1)(F) -123456789012345
           (G) Other retention charges ................................................................            9c(1)(G) -123456789012345
           (H) Total retention ........................................................................................................................................   9c(1)(H)                  123456789012345 
       (2) Dividends or retroactive rate refunds.  (These amounts were   Xpaid in cash, or   Xcredited.) ..................                                               9c(2)                     123456789012345 
    d  Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ...............                                               9d(1)                     123456789012345 
       (2) Claim reserves .............................................................................................................................................   9d(2)                     123456789012345 
       (3) Other reserves ..............................................................................................................................................  9d(3)                     123456789012345 
    e  Dividends or retroactive rate refunds due.  (Do not include amount entered in line 9c(2).) ..............................                                          9e                        123456789012345 
10 Nonexperience-rated contracts: 
    a  Total premiums or subscription charges paid to carrier .....................................................................................                       10a                       123456789012345 
    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, line 2 above, report amount. ..........................                                        10b                       123456789012345 
   Specify nature of costs.  
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD ABCDEFGHI ABCDEFGHI 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHISAMPLEABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 

Part IV    Provision of Information 
11 Did the insurance company fail to provide any information necessary to complete Schedule A? .............                                  X                           Yes                    X No 
12 If the answer to line 11 is “Yes,” specify the information not provided. 
                                      ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
   ABCDEFGHI ABCDE