CAA Disclosure

Broker Name

Company Name

Anniversary Date(Required)

Plan Year End Date

Group Administrator Email

Medical Group Number

Medical Carrier

Medical Commission Schedule

Dental Carrier

Dental Group Number

Dental Commission Schedule

Vision Group Number

Vision Carrier

Vision Commission Schedule

Life Carrier

Life Policy Number

Life/AD&D Commission Schedule

Longterm Disability Carrier

LTD Commission Schedule

LTD Policy Number

Chiro/Acupuncture Carrier

Chiro/Acupuncture Commission Schedule

CAA ERISA Fiduciary

CAA Disclosure

BROKER COMPENSATION DISCLOSURE

The Consolidated Appropriations Act (CAA) of 2021 requires health insurance brokers and consultants to disclose direct and indirect compensation earned on health plans to plan fiduciaries, for contracts entered into or renewed on, or after, December 27, 2021.

The following constitutes Lake Forest Insurance Agency, Inc. (the "Broker") disclosure of direct and indirect compensation the Broker will receive or reasonably expects to receive for the plan period beginning  through  in connection with the below referenced services it provides to  (the "Client" or "you"):

Consulting or brokerage services that apply:

The Broker Does not provide the above-referenced services to Client in the capacity of an ERISA plan fiduciary.

DIRECT COMPENSATION

The Company reasonably expects to receive direct compensation for the placement of the below lines of coverage in the form of either a per employee per month ("PEPM") fee or a commission or flat fee, directly from Client in the amount indicated below:

Coverage or Service: Carrier/Vendor: Commission Schedule

Medical: :

Dental: :

Vision: :

Life/AD&D: :

LTD: :

Chiropractic/Acupuncture: Choice Builder:

INDIRECT COMPENSATION

In addition to the above, the Broker reasonably expects to receive the following indirect compensation from the following other entities:

NONE

OTHER COMPENSATION

The Broker may earn additional compensation from any of the above referenced insurers, vendors, or other third parties that cannot be calculated as of the time this disclosure is made to you, or prior to the date the Broker's executed, extended, or renewed contract with you is effective. For example, the Broker may receive additional compensation contingent upon certain conditions being met, including, but not limited to, profitability, growth, churn/retention, or the volume of services provided.

Compensation may be in the form of additional commissions, bonuses or benefits ("compensation"). Furthermore, we may receive corporate sponsorships for webinars, training or other programming we provide for you and other clients, or for our own internal trainings. Whether we receive any of the above referenced compensation, or how much that compensation may be, cannot be discerned at this time.

Should you have any questions about any of the above information or require additional information, please don't hesitate to contact Jeff Rivera at jeff@insurance-life.com.

The above information is accurate to the best of my knowledge as of the date this disclosure is executed above.

Co-Broker Split Disclosure

Broker Signature Date

Broker Signature

Co-Broker Email

Co-Broker Agency

Primary Broker Commission Split

Co-Broker Commission Split

Co-Broker Signature

Co-Broker Signature Date

CAA Disclosure Client Acknowledgement

Client Job Title

Client Signature

CAA Disclosure

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