B&B HOSPITALITY GROUP has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN
401k plan membership statisitcs for B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2018: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-05-01 | 2,008 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 1,392 |
| Number of retired or separated participants receiving benefits | 2018-05-01 | 27 |
| Number of other retired or separated participants entitled to future benefits | 2018-05-01 | 0 |
| Total of all active and inactive participants | 2018-05-01 | 1,419 |
| 2017: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-05-01 | 1,023 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 1,116 |
| Number of retired or separated participants receiving benefits | 2017-05-01 | 23 |
| Total of all active and inactive participants | 2017-05-01 | 1,139 |
| 2016: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-05-01 | 1,058 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 1,013 |
| Number of retired or separated participants receiving benefits | 2016-05-01 | 10 |
| Number of other retired or separated participants entitled to future benefits | 2016-05-01 | 0 |
| Total of all active and inactive participants | 2016-05-01 | 1,023 |
| 2015: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-05-01 | 1,114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 1,051 |
| Number of retired or separated participants receiving benefits | 2015-05-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2015-05-01 | 0 |
| Total of all active and inactive participants | 2015-05-01 | 1,058 |
| 2014: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-05-01 | 1,064 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-05-01 | 1,074 |
| Number of retired or separated participants receiving benefits | 2014-05-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2014-05-01 | 29 |
| Total of all active and inactive participants | 2014-05-01 | 1,114 |
| 2013: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 944 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 1,008 |
| Number of retired or separated participants receiving benefits | 2013-05-01 | 27 |
| Number of other retired or separated participants entitled to future benefits | 2013-05-01 | 29 |
| Total of all active and inactive participants | 2013-05-01 | 1,064 |
| 2012: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 795 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 886 |
| Number of retired or separated participants receiving benefits | 2012-05-01 | 29 |
| Number of other retired or separated participants entitled to future benefits | 2012-05-01 | 29 |
| Total of all active and inactive participants | 2012-05-01 | 944 |
| 2018: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-05-01 | Type of plan entity | Single employer plan |
| 2018-05-01 | Submission has been amended | No |
| 2018-05-01 | This submission is the final filing | No |
| 2018-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-05-01 | Plan is a collectively bargained plan | No |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-05-01 | Type of plan entity | Single employer plan |
| 2017-05-01 | Submission has been amended | No |
| 2017-05-01 | This submission is the final filing | No |
| 2017-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-05-01 | Plan is a collectively bargained plan | No |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-05-01 | Type of plan entity | Single employer plan |
| 2016-05-01 | Submission has been amended | No |
| 2016-05-01 | This submission is the final filing | No |
| 2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-05-01 | Plan is a collectively bargained plan | No |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Submission has been amended | No |
| 2015-05-01 | This submission is the final filing | No |
| 2015-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-05-01 | Plan is a collectively bargained plan | No |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-05-01 | Type of plan entity | Single employer plan |
| 2014-05-01 | Submission has been amended | No |
| 2014-05-01 | This submission is the final filing | No |
| 2014-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-05-01 | Plan is a collectively bargained plan | No |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Submission has been amended | No |
| 2013-05-01 | This submission is the final filing | No |
| 2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-05-01 | Plan is a collectively bargained plan | No |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: B & B HOSPITALITY GROUP HEALTH AND WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | First time form 5500 has been submitted | Yes |
| 2012-05-01 | Submission has been amended | No |
| 2012-05-01 | This submission is the final filing | No |
| 2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-05-01 | Plan is a collectively bargained plan | No |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 902187 |
| Policy instance | 4 |
| Insurance contract or identification number | 902187 | | Number of Individuals Covered | 678 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $145,519 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | 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 $3,859,178 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $145,519 | | Insurance broker organization code? | 3 |
|
| FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 ) |
| Policy contract number | DBL 252340 |
| Policy instance | 3 |
| Insurance contract or identification number | DBL 252340 | | Number of Individuals Covered | 2145 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $3,989 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 $78,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,989 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4238705 ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | E4238705 ET AL | | Number of Individuals Covered | 88 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $9,824 | | Total amount of fees paid to insurance company | USD $332 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | VOLUNTARY BENEFITS | | 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 $92,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,824 | | Amount paid for insurance broker fees | 332 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E4238473 ET AL |
| Policy instance | 2 |
| Insurance contract or identification number | E4238473 ET AL | | Number of Individuals Covered | 127 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $10,704 | | Total amount of fees paid to insurance company | USD $279 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | VOLUNTARY BENEFITS | | 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 $104,662 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,704 | | Amount paid for insurance broker fees | 279 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4238622 ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | E4238622 ET AL | | Number of Individuals Covered | 198 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $30,004 | | Total amount of fees paid to insurance company | USD $5,018 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | VOLUNTARY BENEFITS | | 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 $139,838 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,004 | | Amount paid for insurance broker fees | 5018 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | CORP SYNERGIES AND VARIOUS AGENTS |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E4238598 ET AL |
| Policy instance | 2 |
| Insurance contract or identification number | E4238598 ET AL | | Number of Individuals Covered | 174 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $24,514 | | Total amount of fees paid to insurance company | USD $4,625 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | VOLUNTARY BENEFITS | | 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 $122,723 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,514 | | Amount paid for insurance broker fees | 4625 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | CORP SYNERGIES AND VARIOUS AGENTS |
|
| THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 ) |
| Policy contract number | D112033 ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | D112033 ET AL | | Number of Individuals Covered | 1116 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $5,214 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 $43,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,214 | | Insurance broker organization code? | 3 | | Insurance broker name | GLOBAL COVERAGE INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 902187 |
| Policy instance | 4 |
| Insurance contract or identification number | 902187 | | Number of Individuals Covered | 985 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $152,442 | | Total amount of fees paid to insurance company | USD $7,000 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | 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 $3,814,217 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $152,442 | | Amount paid for insurance broker fees | 7000 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE SYNERGIES GROUP LLC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 902187 |
| Policy instance | 4 |
| Insurance contract or identification number | 902187 | | Number of Individuals Covered | 1051 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $187,793 | | Total amount of fees paid to insurance company | USD $6,185 | | 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 | 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 $4,837,805 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $187,793 | | Amount paid for insurance broker fees | 6000 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE SYNERGIES GROUP LLC |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E4227237 ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | E4227237 ET AL | | Number of Individuals Covered | 63 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $7,418 | | Total amount of fees paid to insurance company | USD $278 | | 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 | VOLUNTARY BENEFITS | | 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 $50,712 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,287 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 80 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | DONALD C SAVOY INC TA SAVOY ASSOC |
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| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E4238515 |
| Policy instance | 2 |
| Insurance contract or identification number | E4238515 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $28 | | 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 | VOLUNTARY BENEFITS | | 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 $78 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14 | | Insurance broker organization code? | 3 | | Insurance broker name | BRAD BIEL |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4238598 ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | E4238598 ET AL | | Number of Individuals Covered | 71 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $5,634 | | Total amount of fees paid to insurance company | USD $681 | | 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 | VOLUNTARY BENEFITS | | 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 $42,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,517 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 137 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | EDUARDO LUY |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 902187 |
| Policy instance | 5 |
| Insurance contract or identification number | 902187 | | Number of Individuals Covered | 1074 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $176,931 | | Total amount of fees paid to insurance company | USD $16,034 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | 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 $4,553,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $176,931 | | Amount paid for insurance broker fees | 16034 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
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| THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 ) |
| Policy contract number | D112033 |
| Policy instance | 4 |
| Insurance contract or identification number | D112033 | | Number of Individuals Covered | 1110 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $6,655 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 $32,749 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,655 | | Insurance broker organization code? | 3 |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4238598 ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | E4238598 ET AL | | Number of Individuals Covered | 72 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $35,923 | | Total amount of fees paid to insurance company | USD $21,102 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | VOLUNTARY BENEFITS | | 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 $67,057 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,751 | | Amount paid for insurance broker fees | 5635 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 902187 |
| Policy instance | 1 |
| Insurance contract or identification number | 902187 | | Number of Individuals Covered | 1074 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $176,931 | | Total amount of fees paid to insurance company | USD $16,034 | | 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 | 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 $4,553,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $176,931 | | Amount paid for insurance broker fees | 16034 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE SYNERGIES GROUP LLC |
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| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E4238515/23 |
| Policy instance | 2 |
| Insurance contract or identification number | E4238515/23 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $1,667 | | Total amount of fees paid to insurance company | USD $311 | | 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 | VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,113 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $820 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 183 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | CARMEN E DIEZ CANSECO |
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| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E4227237 ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | E4227237 ET AL | | Number of Individuals Covered | 71 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $27,515 | | Total amount of fees paid to insurance company | USD $7,094 | | 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 | VOLUNTARY BENEFITS | | 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 $50,652 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,225 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3016 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | HORIZON BENEFITS LLC |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4238598 ET AL |
| Policy instance | 4 |
| Insurance contract or identification number | E4238598 ET AL | | Number of Individuals Covered | 72 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $35,923 | | Total amount of fees paid to insurance company | USD $21,102 | | 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 | VOLUNTARY BENEFITS | | 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 $67,057 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,751 | | Amount paid for insurance broker fees | 5635 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | VALOR BENEFITS |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3335882 |
| Policy instance | 2 |
| Insurance contract or identification number | 3335882 | | Number of Individuals Covered | 1008 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $172,841 | | Total amount of fees paid to insurance company | USD $24,230 | | 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 | 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 $812,216 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $172,841 | | Amount paid for insurance broker fees | 24230 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE SYNERGIES GROUP, LLC |
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| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | YF604/NS788 |
| Policy instance | 1 |
| Insurance contract or identification number | YF604/NS788 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $15,922 | | Total amount of fees paid to insurance company | USD $526 | | 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 | | Other welfare benefits provided | ACCIDENT CANCER | | 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 $112,953 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,922 | | Amount paid for insurance broker fees | 526 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | MAURICE LYONS AND VARIOUS AGENTS |
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| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | YF604 |
| Policy instance | 3 |
| Insurance contract or identification number | YF604 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $20,021 | | Total amount of fees paid to insurance company | USD $599 | | 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 | ACCIDENT, CANCER, VOLUNTARY SHORT TERM DISABILITY | | 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 $76,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,338 | | Amount paid for insurance broker fees | 100 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | TIMOTHY R QUINLAN |
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| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | NS788 |
| Policy instance | 2 |
| Insurance contract or identification number | NS788 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $17,494 | | Total amount of fees paid to insurance company | USD $702 | | 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 | ACCIDENT, CANCER, VOLUNTARY SHORT TERM DISABILITY | | 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 $99,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,103 | | Amount paid for insurance broker fees | 113 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | MANUEL I MADRID |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3335882 |
| Policy instance | 1 |
| Insurance contract or identification number | 3335882 | | Number of Individuals Covered | 967 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $145,750 | | 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 | 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 | | Other welfare benefits provided | PREPAID DENTAL | | 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 $760,624 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $145,750 | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE SYNERGIES GROUP LLC |
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