J & R SCHUGEL HOLDINGS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST
401k plan membership statisitcs for J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST
| Measure | Date | Value |
|---|
| 2021: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 462 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 429 |
| Total of all active and inactive participants | 2021-10-01 | 429 |
| Total participants | 2021-10-01 | 429 |
| 2020: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 602 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 462 |
| Total of all active and inactive participants | 2020-10-01 | 462 |
| Total participants | 2020-10-01 | 462 |
| 2019: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 657 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 602 |
| Total of all active and inactive participants | 2019-10-01 | 602 |
| Total participants | 2019-10-01 | 602 |
| 2018: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 358 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 657 |
| Total of all active and inactive participants | 2018-10-01 | 657 |
| Total participants | 2018-10-01 | 657 |
| 2017: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 365 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 358 |
| Total of all active and inactive participants | 2017-10-01 | 358 |
| Total participants | 2017-10-01 | 358 |
| 2016: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 373 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 365 |
| Total of all active and inactive participants | 2016-10-01 | 365 |
| Total participants | 2016-10-01 | 365 |
| 2015: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 371 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 372 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 1 |
| Total of all active and inactive participants | 2015-10-01 | 373 |
| Total participants | 2015-10-01 | 373 |
| 2014: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 392 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 370 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 1 |
| Total of all active and inactive participants | 2014-10-01 | 371 |
| Total participants | 2014-10-01 | 371 |
| 2013: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 373 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 391 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 1 |
| Total of all active and inactive participants | 2013-10-01 | 392 |
| 2012: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 400 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 373 |
| Total of all active and inactive participants | 2012-10-01 | 373 |
| 2011: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 400 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 400 |
| Total of all active and inactive participants | 2011-10-01 | 400 |
| 2010: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-10-01 | 422 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 400 |
| Total of all active and inactive participants | 2010-10-01 | 400 |
| 2009: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 458 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 422 |
| Total of all active and inactive participants | 2009-10-01 | 422 |
| 2021: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Submission has been amended | No |
| 2021-10-01 | This submission is the final filing | No |
| 2021-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-10-01 | Plan is a collectively bargained plan | No |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Submission has been amended | No |
| 2020-10-01 | This submission is the final filing | No |
| 2020-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-10-01 | Plan is a collectively bargained plan | No |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Submission has been amended | No |
| 2019-10-01 | This submission is the final filing | No |
| 2019-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-10-01 | Plan is a collectively bargained plan | No |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Submission has been amended | No |
| 2018-10-01 | This submission is the final filing | No |
| 2018-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-10-01 | Plan is a collectively bargained plan | No |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Submission has been amended | No |
| 2017-10-01 | This submission is the final filing | No |
| 2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-10-01 | Plan is a collectively bargained plan | No |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Submission has been amended | No |
| 2016-10-01 | This submission is the final filing | No |
| 2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-10-01 | Plan is a collectively bargained plan | No |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2010 form 5500 responses |
|---|
| 2010-10-01 | Type of plan entity | Single employer plan |
| 2010-10-01 | Plan funding arrangement – Insurance | Yes |
| 2010-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: J & R SCHUGEL HOLDINGS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2009 form 5500 responses |
|---|
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 921963 |
| Policy instance | 2 |
| Insurance contract or identification number | 921963 | | Number of Individuals Covered | 429 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $96,080 | | Total amount of fees paid to insurance company | USD $32,400 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | 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 $5,472,452 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,381 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 931837 |
| Policy instance | 1 |
| Insurance contract or identification number | 931837 | | Number of Individuals Covered | 312 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $68,343 | | Total amount of fees paid to insurance company | USD $17,603 | | 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 | Yes | | 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 $565,370 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,074 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | BONUSES |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0921963 |
| Policy instance | 2 |
| Insurance contract or identification number | 0921963 | | Number of Individuals Covered | 462 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $67,378 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | 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 $4,975,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,117 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 0 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 931837 |
| Policy instance | 1 |
| Insurance contract or identification number | 931837 | | Number of Individuals Covered | 400 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $73,859 | | Total amount of fees paid to insurance company | USD $18,070 | | 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 | Yes | | 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 $618,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,365 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 18070 | | Additional information about fees paid to insurance broker | BONUSES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 931837 |
| Policy instance | 3 |
| Insurance contract or identification number | 931837 | | Number of Individuals Covered | 386 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $71,120 | | 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 | Yes | | 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 $696,044 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $71,120 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 050747 |
| Policy instance | 2 |
| Insurance contract or identification number | 050747 | | Number of Individuals Covered | 947 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $12,127 | | 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 $0 | | Amount paid for insurance broker fees | 12127 | | Additional information about fees paid to insurance broker | ADMINISTATIVE SERVICE FEES | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97037031001 |
| Policy instance | 1 |
| Insurance contract or identification number | 97037031001 | | Number of Individuals Covered | 749 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $5,335 | | 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 $53,045 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,335 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 179500 |
| Policy instance | 4 |
| Insurance contract or identification number | 179500 | | Number of Individuals Covered | 916 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $76,014 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $5,471,138 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $76,014 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97037031001 |
| Policy instance | 2 |
| Insurance contract or identification number | 97037031001 | | Number of Individuals Covered | 831 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $4,684 | | 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 $55,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,684 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5480734 |
| Policy instance | 3 |
| Insurance contract or identification number | 5480734 | | Number of Individuals Covered | 647 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $120,452 | | Total amount of fees paid to insurance company | USD $6,422 | | 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 | Yes | | 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 $696,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $120,452 | | Amount paid for insurance broker fees | 6422 | | Additional information about fees paid to insurance broker | FEES AND OTHER COMMISSIONS PAID | | Insurance broker organization code? | 3 |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 179500 |
| Policy instance | 4 |
| Insurance contract or identification number | 179500 | | Number of Individuals Covered | 1032 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $83,026 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $6,174,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $83,026 | | Amount paid for insurance broker fees | 0 |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 0000062741 |
| Policy instance | 1 |
| Insurance contract or identification number | 0000062741 | | Number of Individuals Covered | 1029 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $12,649 | | 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 $0 | | Amount paid for insurance broker fees | 12649 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICE FEES | | Insurance broker organization code? | 3 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5480734 |
| Policy instance | 1 |
| Insurance contract or identification number | 5480734 | | Number of Individuals Covered | 364 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $58,562 | | 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 | Yes | | 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 $335,391 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 179500 |
| Policy instance | 2 |
| Insurance contract or identification number | 179500 | | Number of Individuals Covered | 531 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $87,470 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $3,088,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97037031001 |
| Policy instance | 3 |
| Insurance contract or identification number | 97037031001 | | Number of Individuals Covered | 372 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $2,803 | | 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 $28,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 0000062741 |
| Policy instance | 4 |
| Insurance contract or identification number | 0000062741 | | Number of Individuals Covered | 529 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $10,765 | | 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 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97037031001 |
| Policy instance | 4 |
| Insurance contract or identification number | 97037031001 | | Number of Individuals Covered | 323 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $2,419 | | 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 $24,295 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,419 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 0000062741 |
| Policy instance | 3 |
| Insurance contract or identification number | 0000062741 | | Number of Individuals Covered | 611 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $5,955 | | 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 $0 | | Amount paid for insurance broker fees | 5955 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | CN566 |
| Policy instance | 1 |
| Insurance contract or identification number | CN566 | | Number of Individuals Covered | 592 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $91,976 | | Total amount of fees paid to insurance company | USD $16,182 | | 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 $3,686,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $91,976 | | Amount paid for insurance broker fees | 16182 | | Additional information about fees paid to insurance broker | CONTINGENT COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50022524 |
| Policy instance | 2 |
| Insurance contract or identification number | 50022524 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $3,694 | | 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 | | 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 $18,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $853 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9703703 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703703 | | Number of Individuals Covered | 310 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $2,420 | | 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 $24,096 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,420 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 0000062741 |
| Policy instance | 3 |
| Insurance contract or identification number | 0000062741 | | Number of Individuals Covered | 575 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $9,985 | | 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 $0 | | Amount paid for insurance broker fees | 9985 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | CN566 |
| Policy instance | 1 |
| Insurance contract or identification number | CN566 | | Number of Individuals Covered | 588 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $89,078 | | Total amount of fees paid to insurance company | USD $7,225 | | 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 $3,557,031 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $89,078 | | Amount paid for insurance broker fees | 7225 | | Additional information about fees paid to insurance broker | CONTINGENT COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 101328201 |
| Policy instance | 2 |
| Insurance contract or identification number | 101328201 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $2,962 | | 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 | | 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 $19,746 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,962 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9703703 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703703 | | Number of Individuals Covered | 322 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $2,460 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,210 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,460 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 050747 |
| Policy instance | 3 |
| Insurance contract or identification number | 050747 | | Number of Individuals Covered | 611 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of fees paid to insurance company | USD $7,399 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 7399 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 101328201 |
| Policy instance | 2 |
| Insurance contract or identification number | 101328201 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $1,242 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,848 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,242 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | CN566,CN705 |
| Policy instance | 1 |
| Insurance contract or identification number | CN566,CN705 | | Number of Individuals Covered | 658 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $369,740 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,638,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $369,740 | | Additional information about fees paid to insurance broker | CONTINGENT COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 101328201 |
| Policy instance | 2 |
| Insurance contract or identification number | 101328201 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $3,001 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,007 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,001 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 050747 |
| Policy instance | 3 |
| Insurance contract or identification number | 050747 | | Number of Individuals Covered | 377 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of fees paid to insurance company | USD $8,528 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 8528 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | CN566,CN705 |
| Policy instance | 1 |
| Insurance contract or identification number | CN566,CN705 | | Number of Individuals Covered | 658 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $87,252 | | Total amount of fees paid to insurance company | USD $588 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,497,203 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $87,252 | | Amount paid for insurance broker fees | 588 | | Additional information about fees paid to insurance broker | CONTINGENT COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9703703 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703703 | | Number of Individuals Covered | 373 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $2,937 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,937 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9703703 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703703 | | Number of Individuals Covered | 362 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $2,508 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | CN566CN705 |
| Policy instance | 1 |
| Insurance contract or identification number | CN566CN705 | | Number of Individuals Covered | 646 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $77,938 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,051,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 101328201 |
| Policy instance | 2 |
| Insurance contract or identification number | 101328201 | | Number of Individuals Covered | 369 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $3,678 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,512 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 050747 |
| Policy instance | 3 |
| Insurance contract or identification number | 050747 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of fees paid to insurance company | USD $8,786 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL PLAN OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 050747 |
| Policy instance | 3 |
| Insurance contract or identification number | 050747 | | Number of Individuals Covered | 391 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of fees paid to insurance company | USD $8,706 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | CN566CN705 |
| Policy instance | 1 |
| Insurance contract or identification number | CN566CN705 | | Number of Individuals Covered | 705 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $71,510 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,116,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9703703 |
| Policy instance | 4 |
| Insurance contract or identification number | 9703703 | | Number of Individuals Covered | 371 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $2,804 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 101328201 |
| Policy instance | 2 |
| Insurance contract or identification number | 101328201 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $2,497 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,489 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
