P & S SURGERY CENTER, LLC DBA P & S SURGICAL HOSPITAL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan P & S SURGICAL HOSPITAL EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for P & S SURGICAL HOSPITAL EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2014 : P & S SURGICAL HOSPITAL EMPLOYEE BENEFIT PLAN 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $237,322 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $226,606 |
| Total income from all sources (including contributions) | 2014-12-31 | $2,443,454 |
| Total loss/gain on sale of assets | 2014-12-31 | $0 |
| Total of all expenses incurred | 2014-12-31 | $2,443,454 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-12-31 | $1,962,651 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-12-31 | $2,443,454 |
| Value of total assets at end of year | 2014-12-31 | $237,322 |
| Value of total assets at beginning of year | 2014-12-31 | $226,606 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-12-31 | $480,803 |
| Total interest from all sources | 2014-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-12-31 | No |
| Administrative expenses professional fees incurred | 2014-12-31 | $480,803 |
| Was this plan covered by a fidelity bond | 2014-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2014-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-12-31 | No |
| Contributions received from participants | 2014-12-31 | $415,622 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2014-12-31 | $163,770 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2014-12-31 | $29,601 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2014-12-31 | $27,581 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Value of net income/loss | 2014-12-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2014-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-12-31 | No |
| Contributions received in cash from employer | 2014-12-31 | $1,864,062 |
| Employer contributions (assets) at end of year | 2014-12-31 | $237,322 |
| Employer contributions (assets) at beginning of year | 2014-12-31 | $226,606 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-12-31 | $1,962,651 |
| Liabilities. Value of benefit claims payable at end of year | 2014-12-31 | $207,721 |
| Liabilities. Value of benefit claims payable at beginning of year | 2014-12-31 | $199,025 |
| Did the plan have assets held for investment | 2014-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-12-31 | Unqualified |
| Accountancy firm name | 2014-12-31 | HEARD MCELROY & VESTAL, LLC |
| Accountancy firm EIN | 2014-12-31 | 720398470 |
| 2013 : P & S SURGICAL HOSPITAL EMPLOYEE BENEFIT PLAN 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $226,606 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $295,727 |
| Total income from all sources (including contributions) | 2013-12-31 | $1,773,828 |
| Total loss/gain on sale of assets | 2013-12-31 | $0 |
| Total of all expenses incurred | 2013-12-31 | $1,773,828 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-12-31 | $1,273,491 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-12-31 | $1,773,828 |
| Value of total assets at end of year | 2013-12-31 | $226,606 |
| Value of total assets at beginning of year | 2013-12-31 | $295,727 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-12-31 | $500,337 |
| Total interest from all sources | 2013-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-12-31 | No |
| Was this plan covered by a fidelity bond | 2013-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2013-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-12-31 | No |
| Contributions received from participants | 2013-12-31 | $400,811 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2013-12-31 | $10,889 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-12-31 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-12-31 | $38,841 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2013-12-31 | $27,581 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2013-12-31 | $295,727 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Value of net income/loss | 2013-12-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2013-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-12-31 | No |
| Contributions received in cash from employer | 2013-12-31 | $1,362,128 |
| Employer contributions (assets) at end of year | 2013-12-31 | $226,606 |
| Employer contributions (assets) at beginning of year | 2013-12-31 | $256,886 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-12-31 | $1,273,491 |
| Contract administrator fees | 2013-12-31 | $500,337 |
| Liabilities. Value of benefit claims payable at end of year | 2013-12-31 | $199,025 |
| Liabilities. Value of benefit claims payable at beginning of year | 2013-12-31 | $0 |
| Did the plan have assets held for investment | 2013-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-12-31 | Unqualified |
| Accountancy firm name | 2013-12-31 | HEARD MCELROY & VESTAL, LLC |
| Accountancy firm EIN | 2013-12-31 | 720398470 |
| 2012 : P & S SURGICAL HOSPITAL EMPLOYEE BENEFIT PLAN 2012 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $295,727 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $242,236 |
| Total income from all sources (including contributions) | 2012-12-31 | $1,925,528 |
| Total of all expenses incurred | 2012-12-31 | $1,925,528 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-12-31 | $1,479,776 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-12-31 | $1,925,528 |
| Value of total assets at end of year | 2012-12-31 | $295,727 |
| Value of total assets at beginning of year | 2012-12-31 | $242,236 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-12-31 | $445,752 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-12-31 | No |
| Was this plan covered by a fidelity bond | 2012-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2012-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-12-31 | No |
| Contributions received from participants | 2012-12-31 | $348,519 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2012-12-31 | $228,647 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2012-12-31 | $38,841 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-12-31 | $398 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2012-12-31 | $295,727 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2012-12-31 | $242,236 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Value of net income/loss | 2012-12-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2012-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-12-31 | No |
| Contributions received in cash from employer | 2012-12-31 | $1,348,362 |
| Employer contributions (assets) at end of year | 2012-12-31 | $256,886 |
| Employer contributions (assets) at beginning of year | 2012-12-31 | $241,838 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-12-31 | $1,479,776 |
| Contract administrator fees | 2012-12-31 | $445,752 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2012-12-31 | No |
| Did the plan have assets held for investment | 2012-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-12-31 | Unqualified |
| Accountancy firm name | 2012-12-31 | HEARD MCELROY & VESTAL, LLC |
| Accountancy firm EIN | 2012-12-31 | 720398470 |
| 2011 : P & S SURGICAL HOSPITAL EMPLOYEE BENEFIT PLAN 2011 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $242,236 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $234,463 |
| Total income from all sources (including contributions) | 2011-12-31 | $2,091,577 |
| Total of all expenses incurred | 2011-12-31 | $2,091,577 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-12-31 | $1,630,823 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-12-31 | $2,091,577 |
| Value of total assets at end of year | 2011-12-31 | $242,236 |
| Value of total assets at beginning of year | 2011-12-31 | $234,463 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-12-31 | $460,754 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-12-31 | No |
| Was this plan covered by a fidelity bond | 2011-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2011-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Contributions received from participants | 2011-12-31 | $336,759 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2011-12-31 | $147,970 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-12-31 | $398 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-12-31 | $58,110 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2011-12-31 | $242,236 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2011-12-31 | $234,463 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Value of net income/loss | 2011-12-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2011-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | No |
| Contributions received in cash from employer | 2011-12-31 | $1,606,848 |
| Employer contributions (assets) at end of year | 2011-12-31 | $241,838 |
| Employer contributions (assets) at beginning of year | 2011-12-31 | $176,353 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-12-31 | $1,630,823 |
| Contract administrator fees | 2011-12-31 | $460,754 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2011-12-31 | No |
| Did the plan have assets held for investment | 2011-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-12-31 | Unqualified |
| Accountancy firm name | 2011-12-31 | HEARD MCELROY & VESTAL, LLC |
| Accountancy firm EIN | 2011-12-31 | 720398470 |
| 2010 : P & S SURGICAL HOSPITAL EMPLOYEE BENEFIT PLAN 2010 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $234,463 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $115,199 |
| Total income from all sources (including contributions) | 2010-12-31 | $1,696,384 |
| Total of all expenses incurred | 2010-12-31 | $1,696,384 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2010-12-31 | $1,213,484 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2010-12-31 | $1,696,384 |
| Value of total assets at end of year | 2010-12-31 | $234,463 |
| Value of total assets at beginning of year | 2010-12-31 | $115,199 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2010-12-31 | $482,900 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2010-12-31 | No |
| Was this plan covered by a fidelity bond | 2010-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2010-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2010-12-31 | No |
| Contributions received from participants | 2010-12-31 | $305,704 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2010-12-31 | $192,826 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2010-12-31 | $58,110 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2010-12-31 | $234,463 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2010-12-31 | $115,199 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Value of net income/loss | 2010-12-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2010-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2010-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2010-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2010-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2010-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2010-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2010-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2010-12-31 | No |
| Contributions received in cash from employer | 2010-12-31 | $1,197,854 |
| Employer contributions (assets) at end of year | 2010-12-31 | $176,353 |
| Employer contributions (assets) at beginning of year | 2010-12-31 | $115,199 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2010-12-31 | $1,213,484 |
| Contract administrator fees | 2010-12-31 | $482,900 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2010-12-31 | No |
| Did the plan have assets held for investment | 2010-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2010-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2010-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2010-12-31 | Unqualified |
| Accountancy firm name | 2010-12-31 | HEARD MCELROY & VESTAL, LLP |
| Accountancy firm EIN | 2010-12-31 | 720398470 |
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | NUTA-1291-K |
| Policy instance | 6 |
| Insurance contract or identification number | NUTA-1291-K | | Number of Individuals Covered | 107 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-04-01 | | Total amount of commissions paid to insurance broker | USD $30,164 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $231,142 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,164 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AVNN |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0AVNN | | Number of Individuals Covered | 83 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-09-01 | | Total amount of commissions paid to insurance broker | USD $6,562 | | Total amount of fees paid to insurance company | USD $2,123 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D-VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $43,747 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,562 | | Amount paid for insurance broker fees | 2123 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AVNN |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0AVNN | | Number of Individuals Covered | 124 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-09-01 | | Total amount of commissions paid to insurance broker | USD $5,277 | | Total amount of fees paid to insurance company | USD $1,550 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,177 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,277 | | Amount paid for insurance broker fees | 1550 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AVNN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AVNN | | Number of Individuals Covered | 124 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-09-01 | | Total amount of commissions paid to insurance broker | USD $1,515 | | Total amount of fees paid to insurance company | USD $482 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,515 | | Amount paid for insurance broker fees | 482 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7811839 |
| Policy instance | 2 |
| Insurance contract or identification number | E7811839 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $8,125 | | Total amount of fees paid to insurance company | USD $20 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $48,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,484 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 15 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | NUGIC-120-17 |
| Policy instance | 1 |
| Insurance contract or identification number | NUGIC-120-17 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $13,113 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $100,479 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,113 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AVNN |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0AVNN | | Number of Individuals Covered | 86 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $6,705 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D-VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $44,700 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,705 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AVNN |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0AVNN | | Number of Individuals Covered | 128 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $4,894 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,629 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,894 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY INC |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AVNN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AVNN | | Number of Individuals Covered | 128 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $1,521 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,140 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,521 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY INC |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7811839 |
| Policy instance | 2 |
| Insurance contract or identification number | E7811839 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2107-12-31 | | Total amount of commissions paid to insurance broker | USD $12,972 | | Total amount of fees paid to insurance company | USD $122 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $68,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,704 | | Amount paid for insurance broker fees | 54 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | TODD TRICHEL |
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| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | NUTA-1291 |
| Policy instance | 1 |
| Insurance contract or identification number | NUTA-1291 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2016-04-01 | | Insurance policy end date | 2017-04-01 | | Total amount of commissions paid to insurance broker | USD $30,182 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $231,453 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,182 | | Insurance broker name | INSURANCE SYSTEMS, INC. |
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| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | NUTA-1291 |
| Policy instance | 1 |
| Insurance contract or identification number | NUTA-1291 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-04-01 | | Total amount of commissions paid to insurance broker | USD $39,925 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $266,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,925 | | Insurance broker name | INSURANCE SYSTEMS, INC. |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7811839 |
| Policy instance | 2 |
| Insurance contract or identification number | E7811839 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2105-12-31 | | Total amount of commissions paid to insurance broker | USD $20,006 | | Total amount of fees paid to insurance company | USD $2,607 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $66,564 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,527 | | Amount paid for insurance broker fees | 493 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AVNN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AVNN | | Number of Individuals Covered | 134 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $1,673 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,150 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,673 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY INC |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AVNN |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0AVNN | | Number of Individuals Covered | 134 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $5,448 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,317 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,448 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY INC |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AVNN |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0AVNN | | Number of Individuals Covered | 93 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $6,551 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D-VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $43,673 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,551 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY INC |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7811839 |
| Policy instance | 1 |
| Insurance contract or identification number | E7811839 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $8,688 | | Total amount of fees paid to insurance company | USD $1,040 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SHORT TERM DISABILITY, CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $70,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,771 | | Amount paid for insurance broker fees | 333 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | RIEHM BENEFITS LLC |
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| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | NUTA -1158 |
| Policy instance | 2 |
| Insurance contract or identification number | NUTA -1158 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $54,121 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $360,808 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,121 | | Insurance broker organization code? | 3 | | Insurance broker name | INSURANCE SYSTEMS, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 143447 |
| Policy instance | 3 |
| Insurance contract or identification number | 143447 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $6,149 | | 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 | 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 $73,560 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,149 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 143445 |
| Policy instance | 4 |
| Insurance contract or identification number | 143445 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $8,439 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LIFESTYLE AD&D, LIFE | | 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 $51,604 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,439 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 143445 |
| Policy instance | 4 |
| Insurance contract or identification number | 143445 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,399 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LIFESTYLE AD&D, LIFE | | 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 $49,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,399 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 143447 |
| Policy instance | 3 |
| Insurance contract or identification number | 143447 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $6,127 | | 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 | 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 $78,738 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,127 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY, INC. |
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| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | NUTA -1081 |
| Policy instance | 2 |
| Insurance contract or identification number | NUTA -1081 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | 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 $447,092 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7811839 |
| Policy instance | 1 |
| Insurance contract or identification number | E7811839 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $10,059 | | Total amount of fees paid to insurance company | USD $207 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SHORT TERM DISABILITY, CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $70,226 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,068 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 31 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | CHARLINE T PARKER |
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| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | NUTA -1010 |
| Policy instance | 2 |
| Insurance contract or identification number | NUTA -1010 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $59,728 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $59,728 | | Insurance broker organization code? | 3 | | Insurance broker name | INSURANCE SYSTEMS INC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 143447 |
| Policy instance | 3 |
| Insurance contract or identification number | 143447 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $6,081 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,594 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,081 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY, INC. |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7811839 |
| Policy instance | 1 |
| Insurance contract or identification number | E7811839 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $9,007 | | Total amount of fees paid to insurance company | USD $456 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $64,542 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,166 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 419 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | CAMPBELL MARKETING INC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 143445 |
| Policy instance | 4 |
| Insurance contract or identification number | 143445 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $6,487 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | LIFESTYLE AD&D, LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $43,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,487 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 143445 |
| Policy instance | 4 |
| Insurance contract or identification number | 143445 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $6,588 | | Total amount of fees paid to insurance company | USD $596 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | LIFESTYLE AD&D, LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $41,251 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 143447 |
| Policy instance | 3 |
| Insurance contract or identification number | 143447 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $5,880 | | Total amount of fees paid to insurance company | USD $1,011 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,237 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | GL-0005 |
| Policy instance | 2 |
| Insurance contract or identification number | GL-0005 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $59,567 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7811839 |
| Policy instance | 1 |
| Insurance contract or identification number | E7811839 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $14,035 | | Total amount of fees paid to insurance company | USD $649 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $60,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7811839 |
| Policy instance | 2 |
| Insurance contract or identification number | E7811839 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $6,561 | | Total amount of fees paid to insurance company | USD $52 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $49,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,415 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 8 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | |
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| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | GL-0005 |
| Policy instance | 3 |
| Insurance contract or identification number | GL-0005 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $65,481 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65,481 | | Insurance broker organization code? | 3 | | Insurance broker name | INSURANCE SYSTEMS, INC. |
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| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 863841G |
| Policy instance | 1 |
| Insurance contract or identification number | 863841G | | Number of Individuals Covered | 177 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-11-30 | | Total amount of commissions paid to insurance broker | USD $13,097 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY INSURANCE PRODUCTS | | Welfare Benefit Premiums Paid to Carrier | USD $87,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,097 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS & FARR AGENCY, INC. |
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