NAZARETH COLLEGE OF ROCHESTER has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan WELFARE PLAN FOR EMPLOYEES OF NAZARETH COLLEGE OF ROCHESTER
401k plan membership statisitcs for WELFARE PLAN FOR EMPLOYEES OF NAZARETH COLLEGE OF ROCHESTER
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | TM05391928 |
Policy instance | 2 |
Insurance contract or identification number | TM05391928 | Number of Individuals Covered | 885 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $4,989 | Total amount of fees paid to insurance company | USD $2,208 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $226,633 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,989 | Amount paid for insurance broker fees | 2203 | Additional information about fees paid to insurance broker | NON-MONETARY/SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
|
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
Policy contract number | 505063A / XZ900 |
Policy instance | 1 |
Insurance contract or identification number | 505063A / XZ900 | Number of Individuals Covered | 496 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $2,232 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $22,325 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,232 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 45256 |
Policy instance | 3 |
Insurance contract or identification number | 45256 | Number of Individuals Covered | 261 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $96,778 | Total amount of fees paid to insurance company | USD $0 | Health 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 $96,778 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 500655 |
Policy instance | 4 |
Insurance contract or identification number | 500655 | Number of Individuals Covered | 139 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $21,088 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $510,149 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $21,088 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 5 |
Insurance contract or identification number | ETB-201079 | Number of Individuals Covered | 522 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $113 | Total amount of fees paid to insurance company | USD $15 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $113 | Amount paid for insurance broker fees | 15 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 6 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 51 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $4,140 | Total amount of fees paid to insurance company | USD $99 | Other welfare benefits provided | CANCER | Welfare Benefit Premiums Paid to Carrier | USD $27,733 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,780 | Amount paid for insurance broker fees | 68 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 7 |
Insurance contract or identification number | ETB-201079 | Number of Individuals Covered | 522 | Insurance policy start date | 2021-03-07 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $113 | Total amount of fees paid to insurance company | USD $12 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $113 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | YOK960543 |
Policy instance | 8 |
Insurance contract or identification number | YOK960543 | Number of Individuals Covered | 522 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $22,541 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $322,011 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $22,541 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | NON-MONETARY/SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | YOK960543 |
Policy instance | 5 |
Insurance contract or identification number | YOK960543 | Number of Individuals Covered | 505 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $17,597 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $251,383 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $17,597 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 55271 |
Policy instance | 4 |
Insurance contract or identification number | 55271 | 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 $103,747 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $103,747 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 3 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 62 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $4,153 | Total amount of fees paid to insurance company | USD $47 | Other welfare benefits provided | CANCER | Welfare Benefit Premiums Paid to Carrier | USD $22,714 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,767 | Amount paid for insurance broker fees | 32 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 500655 |
Policy instance | 2 |
Insurance contract or identification number | 500655 | Number of Individuals Covered | 140 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $20,538 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $473,472 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,538 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
Policy contract number | 505063A / XZ900 |
Policy instance | 1 |
Insurance contract or identification number | 505063A / XZ900 | Number of Individuals Covered | 488 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $2,269 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $22,688 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,269 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 6 |
Insurance contract or identification number | ETB-201079 | Number of Individuals Covered | 505 | Insurance policy start date | 2021-03-07 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $226 | Total amount of fees paid to insurance company | USD $29 | 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 | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $1,500 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $113 | Amount paid for insurance broker fees | 12 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
|
DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
Policy contract number | XZ9 |
Policy instance | 1 |
Insurance contract or identification number | XZ9 | Number of Individuals Covered | 502 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $2,377 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $23,769 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,377 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 52717 |
Policy instance | 3 |
Insurance contract or identification number | 52717 | Number of Individuals Covered | 558 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $5,967 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $77,324 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,967 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 55271 |
Policy instance | 5 |
Insurance contract or identification number | 55271 | Number of Individuals Covered | 317 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $125,228 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | 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 | Welfare Benefit Premiums Paid to Carrier | USD $466,906 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $125,228 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | YOK960543 |
Policy instance | 6 |
Insurance contract or identification number | YOK960543 | Number of Individuals Covered | 558 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $13,048 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $93,197 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $13,048 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 4 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 67 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $5,106 | Total amount of fees paid to insurance company | USD $144 | Other welfare benefits provided | CANCER | Welfare Benefit Premiums Paid to Carrier | USD $30,537 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,316 | Amount paid for insurance broker fees | 103 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 2 |
Insurance contract or identification number | ETB-201079 | Insurance policy start date | 2019-03-07 | Insurance policy end date | 2020-03-06 | Total amount of commissions paid to insurance broker | USD $113 | Total amount of fees paid to insurance company | USD $21 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $113 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS |
|
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
Policy contract number | XZ9 001 002 |
Policy instance | 3 |
Insurance contract or identification number | XZ9 001 002 | Number of Individuals Covered | 508 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $2,343 | 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 | 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 $23,426 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,343 | Insurance broker organization code? | 3 |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 6 |
Insurance contract or identification number | ETB-201079 | Insurance policy start date | 2018-03-07 | Insurance policy end date | 2019-03-06 | Total amount of commissions paid to insurance broker | USD $113 | 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 | BUSINESS TRAVEL ACCIDENT | 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 $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $113 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 4 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 62 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $5,559 | Total amount of fees paid to insurance company | USD $191 | 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 | CANCER PROTECTION | 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 $30,714 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,572 | Amount paid for insurance broker fees | 136 | Insurance broker organization code? | 3 |
|
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 52717 |
Policy instance | 5 |
Insurance contract or identification number | 52717 | Number of Individuals Covered | 555 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $14,235 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | 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 $186,234 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,235 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00045256 |
Policy instance | 1 |
Insurance contract or identification number | 00045256 | Number of Individuals Covered | 294 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $90,434 | 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 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $90,434 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00500655 |
Policy instance | 7 |
Insurance contract or identification number | 00500655 | Number of Individuals Covered | 137 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $17,845 | 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 | 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 | 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 $425,207 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,845 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00055271 |
Policy instance | 2 |
Insurance contract or identification number | 00055271 | Number of Individuals Covered | 320 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $10,413 | 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 | Yes | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,413 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 7 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 303 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $9,972 | 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 | Yes | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,972 | Insurance broker organization code? | 3 |
|
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
Policy contract number | 416719 |
Policy instance | 6 |
Insurance contract or identification number | 416719 | Number of Individuals Covered | 121 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $17,413 | 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 | 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 | 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 $356,768 | Commission paid to Insurance Broker | USD $17,413 | Insurance broker organization code? | 3 |
|
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 52717 |
Policy instance | 5 |
Insurance contract or identification number | 52717 | Number of Individuals Covered | 553 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $13,706 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $179,847 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,706 | Insurance broker organization code? | 3 |
|
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
Policy contract number | XZ9 001 002 |
Policy instance | 4 |
Insurance contract or identification number | XZ9 001 002 | Number of Individuals Covered | 489 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $2,242 | 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 | 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 $22,416 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,242 | Insurance broker organization code? | 3 |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 3 |
Insurance contract or identification number | ETB-201079 | Insurance policy start date | 2017-03-07 | Insurance policy end date | 2018-03-08 | Total amount of commissions paid to insurance broker | USD $113 | 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 | BUSINESS TRAVEL ACCIDENT | 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 $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $113 | Insurance broker organization code? | 3 |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 2 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 62 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $3,240 | Total amount of fees paid to insurance company | USD $33 | 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 | CANCER PRTOECTION | 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 $26,424 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,367 | Amount paid for insurance broker fees | 24 | Insurance broker organization code? | 3 |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00045256 |
Policy instance | 1 |
Insurance contract or identification number | 00045256 | Number of Individuals Covered | 292 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $90,900 | 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 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $90,900 | Insurance broker organization code? | 3 |
|
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 ) |
Policy contract number | 10005 |
Policy instance | 6 |
Insurance contract or identification number | 10005 | Number of Individuals Covered | 53 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $2,870 | 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 | LONG TERM CARE | 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 $28,697 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,870 | Insurance broker organization code? | 3 | Insurance broker name | FIRST NIAGARA RISK MANAGEMENT INC |
|
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
Policy contract number | 416719 |
Policy instance | 5 |
Insurance contract or identification number | 416719 | Number of Individuals Covered | 113 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $7,138 | 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 | 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 | 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 $300,169 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,750 | Insurance broker organization code? | 3 | Insurance broker name | FIRST NIAGARA RISK MANAGEMENT |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 4 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 54 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $2,402 | 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 | CANCER PROTECTION PLAN | 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 $26,077 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $954 | Insurance broker organization code? | 3 | Insurance broker name | RUSSELL BARRETT |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 2 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 291 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $10,120 | 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 | Yes | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,120 | Insurance broker organization code? | 3 | Insurance broker name | KEY INSURANCE & BENEFIT SERVICES |
|
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
Policy contract number | XZ9 001 002 |
Policy instance | 3 |
Insurance contract or identification number | XZ9 001 002 | Number of Individuals Covered | 503 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $2,362 | 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 | 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 $23,625 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,363 | Insurance broker organization code? | 3 | Insurance broker name | FIRST NIAGARA BENEFIT CONSULTING |
|
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 52717 |
Policy instance | 7 |
Insurance contract or identification number | 52717 | Number of Individuals Covered | 540 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $13,266 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $173,812 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,266 | Insurance broker organization code? | 3 | Insurance broker name | FIRST NIAGARA RISK MANAGEMENT INC |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00045256 |
Policy instance | 1 |
Insurance contract or identification number | 00045256 | Number of Individuals Covered | 289 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $92,311 | 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 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $92,311 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | KEY INSURANCE & BENEFIT SERVICES |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB201079 |
Policy instance | 8 |
Insurance contract or identification number | ETB201079 | Insurance policy start date | 2016-03-07 | Insurance policy end date | 2017-03-06 | Total amount of commissions paid to insurance broker | USD $113 | 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 | BUSINESS TRAVEL ACCIDENT | 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 $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $113 | Insurance broker organization code? | 3 | Insurance broker name | KEY INSURANCE & BENEFITS SVCS INC |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | FLY051427 |
Policy instance | 7 |
Insurance contract or identification number | FLY051427 | Number of Individuals Covered | 526 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $2,884 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH | 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 $113,545 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12 | Insurance broker organization code? | 3 | Insurance broker name | SMOLA CONSULTING, LLC |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 1 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 278 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $9,889 | 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 | Yes | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,576 | Insurance broker organization code? | 3 | Insurance broker name | FIRST NIAGARA RISK MANAGEMENT, INC. |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00045256 |
Policy instance | 2 |
Insurance contract or identification number | 00045256 | Number of Individuals Covered | 300 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $84,449 | 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 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $28,105 | Insurance broker organization code? | 3 | Insurance broker name | SMOLA CONSULTING, LLC |
|
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
Policy contract number | XZ9 001 002 |
Policy instance | 3 |
Insurance contract or identification number | XZ9 001 002 | Number of Individuals Covered | 242 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $2,337 | 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 | 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 $23,366 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $971 | Insurance broker organization code? | 3 | Insurance broker name | FIRST NIAGARA RISK MANAGEMENT, INC. |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 4 |
Insurance contract or identification number | ETB-201079 | Number of Individuals Covered | 422 | Insurance policy start date | 2014-03-07 | Insurance policy end date | 2015-03-06 | Total amount of commissions paid to insurance broker | 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 | BUSINESS TRAVEL ACCIDENT | 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 $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $188 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 89009 ) |
Policy contract number | 644052 |
Policy instance | 6 |
Insurance contract or identification number | 644052 | Number of Individuals Covered | 549 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $7,571 | 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 | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SHORT TERM DISABILITY | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,699 | Insurance broker organization code? | 3 | Insurance broker name | SMOLA CONSULTING, LLC |
|
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 ) |
Policy contract number | 10005 |
Policy instance | 8 |
Insurance contract or identification number | 10005 | Number of Individuals Covered | 63 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $1,621 | 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 | LONG TERM CARE | 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 $34,415 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,621 | Insurance broker organization code? | 3 | Insurance broker name | FIRST NIAGARA RISK MANAGEMENT, INC. |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 5 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 68 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $4,932 | Total amount of fees paid to insurance company | USD $73 | 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 | CANCER PROTECTION | 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 $27,708 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $2,105 | Amount paid for insurance broker fees | 43 | Insurance broker organization code? | 3 | Insurance broker name | LEWIS K GATHRIGHT JR |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00045256 |
Policy instance | 1 |
Insurance contract or identification number | 00045256 | Number of Individuals Covered | 420 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $82,298 | 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 | 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 | 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 $244,462 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $46,398 | Insurance broker organization code? | 3 | Insurance broker name | SMOLA CONSULTING, LLC |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 2 |
Insurance contract or identification number | ETB-201079 | Number of Individuals Covered | 434 | Insurance policy start date | 2014-03-07 | Insurance policy end date | 2015-03-06 | Total amount of commissions paid to insurance broker | USD $188 | 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 | BUSINESS TRAVEL ACCIDENT | 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 $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $188 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | FLY051427 |
Policy instance | 3 |
Insurance contract or identification number | FLY051427 | Number of Individuals Covered | 521 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $2,769 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH | 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 $106,636 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,881 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | SALES & SERVICE | Insurance broker name | SMOLA CONSULTING, LLC |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 5 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 57 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $2,629 | Total amount of fees paid to insurance company | USD $163 | 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 | CANCER PROTECTION | 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 $22,906 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $941 | Amount paid for insurance broker fees | 102 | Insurance broker organization code? | 3 | Insurance broker name | LEWIS GATHRIGHT, JR |
|
THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 89009 ) |
Policy contract number | 644052 |
Policy instance | 4 |
Insurance contract or identification number | 644052 | Number of Individuals Covered | 259 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $7,274 | 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 | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SHORT TERM DISABILITY | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,130 | Insurance broker organization code? | 3 | Insurance broker name | SMOLA CONSULTING, LLC |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 7 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 273 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $10,657 | 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 | Yes | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,028 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 ) |
Policy contract number | 10005 |
Policy instance | 6 |
Insurance contract or identification number | 10005 | Number of Individuals Covered | 62 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $2,569 | 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 | LONG TERM CARE | 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 $31,522 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,569 | Insurance broker organization code? | 3 | Insurance broker name | SMOLA CONSULTING, LLC |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 8 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 269 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | 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 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 2 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 268 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $9,460 | 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 | Yes | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,460 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 45256 |
Policy instance | 1 |
Insurance contract or identification number | 45256 | Number of Individuals Covered | 425 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $106,801 | 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 | 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 | 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 $221,822 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $106,801 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 8 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 55 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-01 | Total amount of commissions paid to insurance broker | USD $2,917 | 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 | CANCER PROTECTION | 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 $25,654 | 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 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | STEPHEN C. PLATNER |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 3 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 266 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $0 | 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 | 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 $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB201079 |
Policy instance | 7 |
Insurance contract or identification number | ETB201079 | Number of Individuals Covered | 416 | Insurance policy start date | 2013-03-07 | Insurance policy end date | 2014-03-06 | Total amount of commissions paid to insurance broker | USD $150 | 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 | BUSINESS TRAVEL ACCIDENT | 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 $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $150 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | FLY051427 |
Policy instance | 6 |
Insurance contract or identification number | FLY051427 | Number of Individuals Covered | 521 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $4,306 | Total amount of fees paid to insurance company | USD $-275 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH | 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 $97,436 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,306 | Amount paid for insurance broker fees | -275 | Additional information about fees paid to insurance broker | SUPP. COMMISSION AND OVERRIDE | Insurance broker organization code? | 7 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 ) |
Policy contract number | 10005 |
Policy instance | 5 |
Insurance contract or identification number | 10005 | Number of Individuals Covered | 60 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $0 | 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 | GROUP LONG-TERM CARE | 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 $30,711 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 89009 ) |
Policy contract number | 644052 |
Policy instance | 4 |
Insurance contract or identification number | 644052 | Number of Individuals Covered | 285 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $8,130 | 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 | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SHORT-TERM DISABILITY | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,130 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 45256 |
Policy instance | 1 |
Insurance contract or identification number | 45256 | Number of Individuals Covered | 435 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $108,974 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $154,619 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $108,974 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 9 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 61 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $2,826 | Total amount of fees paid to insurance company | USD $22 | Other welfare benefits provided | CANCER PROTECTION | Welfare Benefit Premiums Paid to Carrier | USD $26,634 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $862 | Amount paid for insurance broker fees | 13 | Insurance broker organization code? | 3 | Insurance broker name | LEWIS K. GATHRIGHT, JR |
|
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
Policy contract number | 701180 |
Policy instance | 8 |
Insurance contract or identification number | 701180 | Number of Individuals Covered | 26 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $3,425 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $56,950 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,425 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB201079 |
Policy instance | 7 |
Insurance contract or identification number | ETB201079 | Number of Individuals Covered | 433 | Insurance policy start date | 2012-03-01 | Insurance policy end date | 2013-02-28 | Total amount of commissions paid to insurance broker | USD $150 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $150 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | FLY051427 |
Policy instance | 6 |
Insurance contract or identification number | FLY051427 | Number of Individuals Covered | 536 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $3,017 | Total amount of fees paid to insurance company | USD $275 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH | Welfare Benefit Premiums Paid to Carrier | USD $111,522 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,017 | Amount paid for insurance broker fees | 275 | Insurance broker organization code? | 7 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 ) |
Policy contract number | 10005 |
Policy instance | 5 |
Insurance contract or identification number | 10005 | Number of Individuals Covered | 59 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | GROUP LONG-TERM CARE | Welfare Benefit Premiums Paid to Carrier | USD $28,477 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 2 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 279 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $9,514 | Total amount of fees paid to insurance company | USD $0 | Dental 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 $9,514 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 3 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 269 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | 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 $0 | Insurance broker name | |
|
THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 89009 ) |
Policy contract number | 644052 |
Policy instance | 4 |
Insurance contract or identification number | 644052 | Number of Individuals Covered | 396 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $8,466 | Total amount of fees paid to insurance company | USD $0 | Long Term Disability 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 $8,466 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 1 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 60 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $3,364 | Total amount of fees paid to insurance company | USD $179 | Other welfare benefits provided | CANCER PROTECTION | Welfare Benefit Premiums Paid to Carrier | USD $26,708 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 89009 ) |
Policy contract number | 644052 |
Policy instance | 9 |
Insurance contract or identification number | 644052 | Number of Individuals Covered | 408 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $9,529 | Total amount of fees paid to insurance company | USD $0 | Long Term Disability Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 5 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 274 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
Policy contract number | B011801065 |
Policy instance | 8 |
Insurance contract or identification number | B011801065 | Number of Individuals Covered | 28 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $3,713 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $64,676 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | ETB-201079 |
Policy instance | 7 |
Insurance contract or identification number | ETB-201079 | Number of Individuals Covered | 444 | Insurance policy start date | 2011-03-01 | Insurance policy end date | 2012-02-29 | Total amount of commissions paid to insurance broker | USD $113 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 6 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 286 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $7,271 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 ) |
Policy contract number | 10005 |
Policy instance | 3 |
Insurance contract or identification number | 10005 | Number of Individuals Covered | 60 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | GROUP LONG-TERM CARE | Welfare Benefit Premiums Paid to Carrier | USD $25,914 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | FLY051427 |
Policy instance | 2 |
Insurance contract or identification number | FLY051427 | Number of Individuals Covered | 552 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $4,613 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH | Welfare Benefit Premiums Paid to Carrier | USD $109,972 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 4 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 443 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $98,762 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $283,804 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
Policy contract number | FLY051427 |
Policy instance | 1 |
Insurance contract or identification number | FLY051427 | Number of Individuals Covered | 557 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $3,650 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH | Welfare Benefit Premiums Paid to Carrier | USD $109,836 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,650 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 7 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | NG255 |
Policy instance | 2 |
Insurance contract or identification number | NG255 | Number of Individuals Covered | 61 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $4,853 | Total amount of fees paid to insurance company | USD $182 | Other welfare benefits provided | CANCER PROTECTION | Welfare Benefit Premiums Paid to Carrier | USD $26,909 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,736 | Amount paid for insurance broker fees | 98 | Insurance broker organization code? | 3 | Insurance broker name | LEWIS GATHRIGHT JR |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 4 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 801 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $110,985 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $141,794 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $110,985 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 5 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 580 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $8,840 | Total amount of fees paid to insurance company | USD $0 | Dental 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 $8,840 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 2961 |
Policy instance | 6 |
Insurance contract or identification number | 2961 | Number of Individuals Covered | 582 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
Policy contract number | B011801065 |
Policy instance | 7 |
Insurance contract or identification number | B011801065 | Number of Individuals Covered | 28 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $3,413 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $63,442 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,413 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 89009 ) |
Policy contract number | 644052 |
Policy instance | 8 |
Insurance contract or identification number | 644052 | Number of Individuals Covered | 392 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $12,021 | Total amount of fees paid to insurance company | USD $0 | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | STATE DISABILITY | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,021 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS |
|
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | ETB-201079 |
Policy instance | 9 |
Insurance contract or identification number | ETB-201079 | Number of Individuals Covered | 442 | Insurance policy start date | 2010-03-07 | Insurance policy end date | 2011-03-06 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | TRAVEL ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $750 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
CONTINENTAL CASUALTY COMPANY (National Association of Insurance Commissioners NAIC id number: 20443 ) |
Policy contract number | 10005 |
Policy instance | 3 |
Insurance contract or identification number | 10005 | Number of Individuals Covered | 60 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | GROUP LONG-TERM CARE | Welfare Benefit Premiums Paid to Carrier | USD $26,078 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|