ESSEX COUNTY CHAPTER NYSARC, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN
401k plan membership statisitcs for ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN
| Measure | Date | Value |
|---|
| 2022: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 437 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 457 |
| Total of all active and inactive participants | 2022-01-01 | 457 |
| 2021: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 482 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 437 |
| Total of all active and inactive participants | 2021-01-01 | 437 |
| 2020: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 419 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 482 |
| Total of all active and inactive participants | 2020-01-01 | 482 |
| Total participants | 2020-01-01 | 482 |
| 2019: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 422 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 419 |
| Total of all active and inactive participants | 2019-01-01 | 419 |
| Total participants | 2019-01-01 | 419 |
| 2018: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 516 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 422 |
| Total of all active and inactive participants | 2018-01-01 | 422 |
| Total participants | 2018-01-01 | 422 |
| 2017: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 577 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 516 |
| Total of all active and inactive participants | 2017-01-01 | 516 |
| Total participants | 2017-01-01 | 516 |
| 2016: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 564 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 577 |
| Total of all active and inactive participants | 2016-01-01 | 577 |
| Total participants | 2016-01-01 | 577 |
| 2015: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 558 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 564 |
| Total of all active and inactive participants | 2015-01-01 | 564 |
| Total participants | 2015-01-01 | 0 |
| 2014: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 572 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 558 |
| Total of all active and inactive participants | 2014-01-01 | 558 |
| Total participants | 2014-01-01 | 0 |
| 2013: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 576 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 572 |
| Total of all active and inactive participants | 2013-01-01 | 572 |
| Total participants | 2013-01-01 | 0 |
| 2012: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 536 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 576 |
| Total of all active and inactive participants | 2012-01-01 | 576 |
| Total participants | 2012-01-01 | 0 |
| 2011: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 502 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 536 |
| Total of all active and inactive participants | 2011-01-01 | 536 |
| Total participants | 2011-01-01 | 536 |
| 2009: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 511 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 520 |
| Total of all active and inactive participants | 2009-01-01 | 520 |
| Total participants | 2009-01-01 | 520 |
| 2022: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00532079 |
| Policy instance | 7 |
| Insurance contract or identification number | 00532079 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,254 | | Total amount of fees paid to insurance company | USD $1,085 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,254 | | Amount paid for insurance broker fees | 1085 | | Additional information about fees paid to insurance broker | OTHER FEES | | Insurance broker organization code? | 3 |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 11445352 |
| Policy instance | 1 |
| Insurance contract or identification number | 11445352 | | Number of Individuals Covered | 457 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $93,095 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $93,095 | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0616821 |
| Policy instance | 2 |
| Insurance contract or identification number | R0616821 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $1,683 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GRPACCVO | | Welfare Benefit Premiums Paid to Carrier | USD $9,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,683 | | Additional information about fees paid to insurance broker | BROKER COMMISSIONS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 3 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $2,560 | | Total amount of fees paid to insurance company | USD $2,675 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,560 | | Amount paid for insurance broker fees | 1783 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 4 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $5,064 | | Total amount of fees paid to insurance company | USD $8,880 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,559 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,064 | | Amount paid for insurance broker fees | 5920 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $1,424 | | Total amount of fees paid to insurance company | USD $1,366 | | Other welfare benefits provided | AD&D LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $14,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,424 | | Amount paid for insurance broker fees | 911 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| EBPA, LLC (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | |
| Policy instance | 6 |
| Number of Individuals Covered | 315 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,959 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,959 | | Insurance broker organization code? | 3 |
|
| EBPA, LLC (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | |
| Policy instance | 6 |
| Number of Individuals Covered | 303 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,996 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,996 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,335 | | Total amount of fees paid to insurance company | USD $772 | | Other welfare benefits provided | AD&D LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $13,353 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,335 | | Amount paid for insurance broker fees | 416 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 4 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $4,920 | | Total amount of fees paid to insurance company | USD $4,900 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $86,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,920 | | Amount paid for insurance broker fees | 2638 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 3 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,674 | | Total amount of fees paid to insurance company | USD $1,276 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,674 | | Amount paid for insurance broker fees | 687 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0616821 |
| Policy instance | 2 |
| Insurance contract or identification number | R0616821 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $1,625 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GRPACCVO | | Welfare Benefit Premiums Paid to Carrier | USD $9,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,625 | | Additional information about fees paid to insurance broker | BROKER COMMISSIONS | | Insurance broker organization code? | 3 |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 11445352 |
| Policy instance | 1 |
| Insurance contract or identification number | 11445352 | | Number of Individuals Covered | 437 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $77,591 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $77,591 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 413 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,452 | | Total amount of fees paid to insurance company | USD $2,365 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $34,518 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,452 | | Amount paid for insurance broker fees | 1419 | | Insurance broker organization code? | 5 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00014790 |
| Policy instance | 4 |
| Insurance contract or identification number | 00014790 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,331 | | Total amount of fees paid to insurance company | USD $2,231 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,129 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,331 | | Amount paid for insurance broker fees | 2231 | | Insurance broker organization code? | 5 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00122477 |
| Policy instance | 3 |
| Insurance contract or identification number | 00122477 | | Number of Individuals Covered | 302 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $84,967 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,829,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $84,967 | | Insurance broker organization code? | 5 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 2 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,804 | | Total amount of fees paid to insurance company | USD $5,143 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $82,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,804 | | Amount paid for insurance broker fees | 3086 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 00263 |
| Policy instance | 1 |
| Insurance contract or identification number | 00263 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $17,027 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 13020 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 00263 |
| Policy instance | 1 |
| Insurance contract or identification number | 00263 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $17,650 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 13497 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 2 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,455 | | Total amount of fees paid to insurance company | USD $2,701 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,455 | | Amount paid for insurance broker fees | 2701 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00122477 |
| Policy instance | 3 |
| Insurance contract or identification number | 00122477 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $83,763 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,756,261 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $83,763 | | Insurance broker organization code? | 5 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00014790 |
| Policy instance | 4 |
| Insurance contract or identification number | 00014790 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,241 | | Total amount of fees paid to insurance company | USD $1,887 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,241 | | Amount paid for insurance broker fees | 1887 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 406 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,118 | | Total amount of fees paid to insurance company | USD $1,454 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,118 | | Amount paid for insurance broker fees | 1454 | | Insurance broker organization code? | 5 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00014790 |
| Policy instance | 4 |
| Insurance contract or identification number | 00014790 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,207 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,207 | | Insurance broker organization code? | 5 | | Insurance broker name | ROBERT G RELPH AGENCY INC |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 406385 |
| Policy instance | 3 |
| Insurance contract or identification number | 406385 | | Number of Individuals Covered | 375 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $110,509 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,528,065 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $110,509 | | Insurance broker organization code? | 5 | | Insurance broker name | ROBERT G RELPH AGENCY INC. |
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| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | NY0030 |
| Policy instance | 2 |
| Insurance contract or identification number | NY0030 | | Number of Individuals Covered | 434 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,198 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,198 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT G RELPH AGENCY INC. |
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| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 00263 |
| Policy instance | 1 |
| Insurance contract or identification number | 00263 | | Number of Individuals Covered | 402 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of fees paid to insurance company | USD $20,918 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 15996 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Insurance broker name | NORTHERN INSURING AGENCY |
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