NORTH SHORE BANK has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN
| Measure | Date | Value |
|---|
| 2022: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 444 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 408 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 409 |
| 2021: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 455 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 435 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 435 |
| 2020: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 454 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 452 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 457 |
| 2019: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 453 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 456 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 6 |
| Total of all active and inactive participants | 2019-01-01 | 465 |
| 2018: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 442 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 436 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 2 |
| Total of all active and inactive participants | 2018-01-01 | 445 |
| 2017: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 454 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 438 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 5 |
| Total of all active and inactive participants | 2017-01-01 | 450 |
| 2016: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 415 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 447 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 8 |
| Total of all active and inactive participants | 2016-01-01 | 464 |
| 2015: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 397 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 391 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 24 |
| Total of all active and inactive participants | 2015-01-01 | 426 |
| 2014: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 402 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 378 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 20 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 12 |
| Total of all active and inactive participants | 2014-01-01 | 410 |
| 2013: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 374 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 367 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 15 |
| Total of all active and inactive participants | 2013-01-01 | 389 |
| 2012: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 369 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 544 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 7 |
| Total of all active and inactive participants | 2012-01-01 | 556 |
| 2011: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 338 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 317 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 317 |
| 2010: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 333 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 323 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2010-01-01 | 7 |
| Total of all active and inactive participants | 2010-01-01 | 338 |
| 2009: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 305 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 318 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 7 |
| Total of all active and inactive participants | 2009-01-01 | 333 |
| 2022: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Submission has been amended | No |
| 2010-01-01 | This submission is the final filing | No |
| 2010-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-01-01 | Plan is a collectively bargained plan | No |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: NORTH SHORE BANK EMPLOYEE HEALTH CARE PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169 |
| Policy instance | 5 |
| Insurance contract or identification number | LK963169 | | Number of Individuals Covered | 383 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $997 | | 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 | Yes | | 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 | | Amount paid for insurance broker fees | 997 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK966093 |
| Policy instance | 4 |
| Insurance contract or identification number | OK966093 | | Number of Individuals Covered | 371 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $842 | | Total amount of fees paid to insurance company | 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 | 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 $7,827 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $502 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 113 | | Additional information about fees paid to insurance broker | OVERRIDE |
|
| CARE-PLUS DENTAL PLANS INC. (National Association of Insurance Commissioners NAIC id number: 55328 ) |
| Policy contract number | PPD386 |
| Policy instance | 3 |
| Insurance contract or identification number | PPD386 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,344 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $22,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,344 | | Insurance broker organization code? | 3 |
|
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $6,115 | | 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 | 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 $61,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,834 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX964504 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX964504 | | Number of Individuals Covered | 386 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,412 | | 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 | 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 $68 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1412 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX964504 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX964504 | | Number of Individuals Covered | 416 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,378 | | Total amount of fees paid to insurance company | USD $729 | | 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 | 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 $14,824 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,378 | | Amount paid for insurance broker fees | 729 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,678 | | 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 | 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 $46,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,678 | | Insurance broker organization code? | 3 |
|
| CARE-PLUS DENTAL PLANS INC. (National Association of Insurance Commissioners NAIC id number: 55328 ) |
| Policy contract number | PPD386 |
| Policy instance | 3 |
| Insurance contract or identification number | PPD386 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,687 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $28,108 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,687 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK966093 |
| Policy instance | 4 |
| Insurance contract or identification number | OK966093 | | Number of Individuals Covered | 404 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $111 | | Total amount of fees paid to insurance company | USD $59 | | 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 | 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 $1,113 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $111 | | Amount paid for insurance broker fees | 59 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169 |
| Policy instance | 5 |
| Insurance contract or identification number | LK963169 | | Number of Individuals Covered | 416 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $772 | | Total amount of fees paid to insurance company | USD $496 | | 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 | Yes | | 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 $9,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $772 | | Amount paid for insurance broker fees | 496 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| CARE-PLUS DENTAL PLANS INC. (National Association of Insurance Commissioners NAIC id number: 55328 ) |
| Policy contract number | PPD386 |
| Policy instance | 3 |
| Insurance contract or identification number | PPD386 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,952 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $32,530 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,952 | | Insurance broker organization code? | 3 |
|
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,858 | | 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 | 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 $58,583 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,858 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169* |
| Policy instance | 1 |
| Insurance contract or identification number | LK963169* | | Number of Individuals Covered | 452 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $14,316 | | Total amount of fees paid to insurance company | USD $1,186 | | 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 $154,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,316 | | Amount paid for insurance broker fees | 1186 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| CARE-PLUS DENTAL PLANS INC. (National Association of Insurance Commissioners NAIC id number: 55328 ) |
| Policy contract number | PPD386 |
| Policy instance | 3 |
| Insurance contract or identification number | PPD386 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,862 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $31,041 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,862 | | Insurance broker organization code? | 3 |
|
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,525 | | 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 | 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 $55,250 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,525 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169* |
| Policy instance | 1 |
| Insurance contract or identification number | LK963169* | | Number of Individuals Covered | 456 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $12,635 | | Total amount of fees paid to insurance company | USD $953 | | 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 $134,203 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,635 | | Amount paid for insurance broker fees | 953 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 403 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,161 | | 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 | 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 $47,946 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,161 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169* |
| Policy instance | 1 |
| Insurance contract or identification number | LK963169* | | Number of Individuals Covered | 438 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $10,326 | | Total amount of fees paid to insurance company | USD $1,485 | | 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 $117,841 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,326 | | Amount paid for insurance broker fees | 1485 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN INC. |
|
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $3,895 | | 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 $39,521 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,895 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169* |
| Policy instance | 1 |
| Insurance contract or identification number | LK963169* | | Number of Individuals Covered | 391 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $8,690 | | Total amount of fees paid to insurance company | USD $715 | | 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 | 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 $94,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,690 | | Amount paid for insurance broker fees | 715 | | Additional information about fees paid to insurance broker | SUPP. COMMISSION AND OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169* |
| Policy instance | 1 |
| Insurance contract or identification number | LK963169* | | Number of Individuals Covered | 378 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $8,819 | | Total amount of fees paid to insurance company | USD $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 | 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 $95,404 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,819 | | Amount paid for insurance broker fees | 889 | | Additional information about fees paid to insurance broker | SUPP. COMMISSION AND OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN INC. |
|
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,495 | | 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 $38,082 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,495 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1014630 |
| Policy instance | 3 |
| Insurance contract or identification number | 1014630 | | Number of Individuals Covered | 719 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $8,909 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $274,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,909 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN INC. |
|
| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,584 | | 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 $35,839 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,584 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169* |
| Policy instance | 1 |
| Insurance contract or identification number | LK963169* | | Number of Individuals Covered | 367 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $8,809 | | 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 | 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 $94,141 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,809 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN INC. |
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| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1014630 |
| Policy instance | 3 |
| Insurance contract or identification number | 1014630 | | Number of Individuals Covered | 716 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $8,494 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $257,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,494 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN INC. |
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| SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 ) |
| Policy contract number | 148100 |
| Policy instance | 2 |
| Insurance contract or identification number | 148100 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,844 | | 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 $28,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,844 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963169* |
| Policy instance | 1 |
| Insurance contract or identification number | LK963169* | | Number of Individuals Covered | 544 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $8,154 | | Total amount of fees paid to insurance company | USD $1,384 | | 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 | 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 $84,588 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,154 | | Amount paid for insurance broker fees | 1384 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION AND OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN INC. |
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