401k Plan data: HEALTH PLAN plan

HEALTH PLAN 401k Plan overview

Plan Name	HEALTH PLAN
Plan identification number	501

HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

CZ-USA has sponsored the creation of one or more 401k plans.

Company Name: CZ-USA

Employer identification number (EIN): 770445408

NAIC Classification: 423910
NAIC Description: Sporting and Recreational Goods and Supplies Merchant Wholesalers

Additional information about CZ-USA

Jurisdiction of Incorporation: Nevada Department of State

Incorporation Date: 1997-01-06

Company Identification Number: 19971082177

Legal Registered Office Address: 2500 EAST SECOND STREET SUITE #29

RENO
United States of America (USA)
89595

More information about CZ-USA

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01
501 2020-10-01
501 2019-10-01
501 2018-10-01

Plan Statistics for HEALTH PLAN

401k plan membership statisitcs for HEALTH PLAN

Measure Date Value
2022: HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 127
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 155
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 155
2021: HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 127
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 127
2020: HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year 2020-10-01 112
Total number of active participants reported on line 7a of the Form 5500 2020-10-01 119
Number of retired or separated participants receiving benefits 2020-10-01 0
Number of other retired or separated participants entitled to future benefits 2020-10-01 0
Total of all active and inactive participants 2020-10-01 119
2019: HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 114
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 112
Number of retired or separated participants receiving benefits 2019-10-01 0
Number of other retired or separated participants entitled to future benefits 2019-10-01 0
Total of all active and inactive participants 2019-10-01 112
2018: HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year 2018-10-01 103
Total number of active participants reported on line 7a of the Form 5500 2018-10-01 114
Number of retired or separated participants receiving benefits 2018-10-01 0
Number of other retired or separated participants entitled to future benefits 2018-10-01 0
Total of all active and inactive participants 2018-10-01 114

Measure	Date	Value
2022: HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	127
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	155
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	155
2021: HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	127
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	127
2020: HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year	2020-10-01	112
Total number of active participants reported on line 7a of the Form 5500	2020-10-01	119
Number of retired or separated participants receiving benefits	2020-10-01	0
Number of other retired or separated participants entitled to future benefits	2020-10-01	0
Total of all active and inactive participants	2020-10-01	119
2019: HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	114
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	112
Number of retired or separated participants receiving benefits	2019-10-01	0
Number of other retired or separated participants entitled to future benefits	2019-10-01	0
Total of all active and inactive participants	2019-10-01	112
2018: HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year	2018-10-01	103
Total number of active participants reported on line 7a of the Form 5500	2018-10-01	114
Number of retired or separated participants receiving benefits	2018-10-01	0
Number of other retired or separated participants entitled to future benefits	2018-10-01	0
Total of all active and inactive participants	2018-10-01	114

Form 5500 Responses for HEALTH PLAN

2022: HEALTH PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: HEALTH PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: HEALTH PLAN 2020 form 5500 responses
2020-10-01	Type of plan entity	Single employer plan
2020-10-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2020-10-01	Plan funding arrangement – Insurance	Yes
2020-10-01	Plan benefit arrangement – Insurance	Yes
2019: HEALTH PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes
2018: HEALTH PLAN 2018 form 5500 responses
2018-10-01	Type of plan entity	Single employer plan
2018-10-01	First time form 5500 has been submitted	Yes
2018-10-01	Plan funding arrangement – Insurance	Yes
2018-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

TELADOC, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )

Policy contract number

176121

Policy instance

Insurance contract or identification number	176121
Number of Individuals Covered	155
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $893
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $893
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

918952

Policy instance

Insurance contract or identification number	918952
Number of Individuals Covered	130
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $-104
Total amount of fees paid to insurance company	USD $38,452
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $919,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-104
Amount paid for insurance broker fees	38452
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDS0BLLM

Policy instance

Insurance contract or identification number	GUDS0BLLM
Number of Individuals Covered	86
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,100
Total amount of fees paid to insurance company	USD $2,654
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,100
Amount paid for insurance broker fees	1405
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

GUG 0BLLM

Policy instance

Insurance contract or identification number	GUG 0BLLM
Number of Individuals Covered	88
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,133
Total amount of fees paid to insurance company	USD $1,957
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,133
Amount paid for insurance broker fees	1174
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

GLTD0BLLM

Policy instance

Insurance contract or identification number	GLTD0BLLM
Number of Individuals Covered	88
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,856
Total amount of fees paid to insurance company	USD $2,586
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,856
Amount paid for insurance broker fees	1923
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BLLM

Policy instance

Insurance contract or identification number	GLUG0BLLM
Number of Individuals Covered	88
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,506
Total amount of fees paid to insurance company	USD $1,365
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,506
Amount paid for insurance broker fees	1020
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BLLM

Policy instance

Insurance contract or identification number	GVTL0BLLM
Number of Individuals Covered	41
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,106
Total amount of fees paid to insurance company	USD $1,927
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,106
Amount paid for insurance broker fees	1437
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLLV0BLLM

Policy instance

Insurance contract or identification number	GLLV0BLLM
Number of Individuals Covered	61
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,431
Total amount of fees paid to insurance company	USD $785
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,431
Amount paid for insurance broker fees	471
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

GUDH0BLLM

Policy instance

Insurance contract or identification number	GUDH0BLLM
Number of Individuals Covered	27
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,084
Total amount of fees paid to insurance company	USD $801
Other welfare benefits provided	VOLUNTARY ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $7,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,084
Amount paid for insurance broker fees	625
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BLLM

Policy instance

Insurance contract or identification number	GUDE0BLLM
Number of Individuals Covered	38
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $790
Total amount of fees paid to insurance company	USD $603
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $5,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $790
Amount paid for insurance broker fees	467
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0918952

Policy instance

Insurance contract or identification number	0918952
Number of Individuals Covered	108
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $49,333
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,233,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,333
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDS0BLLM

Policy instance

Insurance contract or identification number	GUDS0BLLM
Number of Individuals Covered	114
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $6,244
Total amount of fees paid to insurance company	USD $2,797
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,244
Amount paid for insurance broker fees	1678
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

GUG 0BLLM

Policy instance

Insurance contract or identification number	GUG 0BLLM
Number of Individuals Covered	127
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,609
Total amount of fees paid to insurance company	USD $2,042
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,609
Amount paid for insurance broker fees	1361
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

GLUG0BLLM

Policy instance

Insurance contract or identification number	GLUG0BLLM
Number of Individuals Covered	127
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,727
Total amount of fees paid to insurance company	USD $1,500
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,727
Amount paid for insurance broker fees	1192
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BLLM

Policy instance

Insurance contract or identification number	GLTD0BLLM
Number of Individuals Covered	127
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,211
Total amount of fees paid to insurance company	USD $2,834
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,211
Amount paid for insurance broker fees	2258
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BLLM

Policy instance

Insurance contract or identification number	GVTL0BLLM
Number of Individuals Covered	68
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,450
Total amount of fees paid to insurance company	USD $1,809
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $16,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,450
Amount paid for insurance broker fees	1478
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLLV0BLLM

Policy instance

Insurance contract or identification number	GLLV0BLLM
Number of Individuals Covered	90
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,571
Total amount of fees paid to insurance company	USD $864
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,571
Amount paid for insurance broker fees	576
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

GUDH0BLLM

Policy instance

Insurance contract or identification number	GUDH0BLLM
Number of Individuals Covered	24
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $881
Total amount of fees paid to insurance company	USD $678
Other welfare benefits provided	VOLUNTARY ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $5,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $881
Amount paid for insurance broker fees	550
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BLLM

Policy instance

Insurance contract or identification number	GUDE0BLLM
Number of Individuals Covered	51
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $678
Total amount of fees paid to insurance company	USD $413
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $4,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $678
Amount paid for insurance broker fees	351
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

616708D

Policy instance

Insurance contract or identification number	616708D
Number of Individuals Covered	10
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $233
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $233
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0BLLM

Policy instance

Insurance contract or identification number	GUG 0BLLM
Number of Individuals Covered	119
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $593
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $593
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0BLLM

Policy instance

Insurance contract or identification number	GUDH0BLLM
Number of Individuals Covered	22
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $203
Total amount of fees paid to insurance company	USD $68
Other welfare benefits provided	VOLUNTARY ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $1,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $203
Amount paid for insurance broker fees	68
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLLV0BLLM

Policy instance

Insurance contract or identification number	GLLV0BLLM
Number of Individuals Covered	86
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $363
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $363
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BLLM

Policy instance

Insurance contract or identification number	GVTL0BLLM
Number of Individuals Covered	63
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $532
Total amount of fees paid to insurance company	USD $177
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $3,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $532
Amount paid for insurance broker fees	177
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BLLM

Policy instance

Insurance contract or identification number	GLUG0BLLM
Number of Individuals Covered	119
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $398
Total amount of fees paid to insurance company	USD $133
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $398
Amount paid for insurance broker fees	133
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BLLM

Policy instance

Insurance contract or identification number	GLTD0BLLM
Number of Individuals Covered	119
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $502
Total amount of fees paid to insurance company	USD $251
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $502
Amount paid for insurance broker fees	251
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDS0BLLM

Policy instance

Insurance contract or identification number	GUDS0BLLM
Number of Individuals Covered	111
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,369
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,369
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0918952

Policy instance

Insurance contract or identification number	0918952
Number of Individuals Covered	129
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,240
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $281,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,240
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BLLM

Policy instance

Insurance contract or identification number	GUDE0BLLM
Number of Individuals Covered	45
Insurance policy start date	2020-10-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $137
Total amount of fees paid to insurance company	USD $46
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $137
Amount paid for insurance broker fees	46
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BLLM

Policy instance

Insurance contract or identification number	GUDE0BLLM
Number of Individuals Covered	25
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $243
Total amount of fees paid to insurance company	USD $111
Other welfare benefits provided	VOLUNTARY CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $1,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $243
Amount paid for insurance broker fees	97
Additional information about fees paid to insurance broker	OTHER COMPENSATION ADMINISTRATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0BLLM

Policy instance

Insurance contract or identification number	GUDH0BLLM
Number of Individuals Covered	16
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $618
Total amount of fees paid to insurance company	USD $284
Other welfare benefits provided	VOLUNTARY ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $618
Amount paid for insurance broker fees	248
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0918952

Policy instance

Insurance contract or identification number	0918952
Number of Individuals Covered	131
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $41,069
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $944,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,069
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLLV0BLLM

Policy instance

Insurance contract or identification number	GLLV0BLLM
Number of Individuals Covered	81
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $1,437
Total amount of fees paid to insurance company	USD $156
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,437
Amount paid for insurance broker fees	84
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

GVTL0BLLM

Policy instance

Insurance contract or identification number	GVTL0BLLM
Number of Individuals Covered	41
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $1,531
Total amount of fees paid to insurance company	USD $659
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,531
Amount paid for insurance broker fees	590
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BLLM

Policy instance

Insurance contract or identification number	GLUG0BLLM
Number of Individuals Covered	112
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $1,528
Total amount of fees paid to insurance company	USD $686
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,528
Amount paid for insurance broker fees	605
Additional information about fees paid to insurance broker	ADMINISTRATION OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0BLLM

Policy instance

Insurance contract or identification number	GUG 0BLLM
Number of Individuals Covered	112
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $2,219
Total amount of fees paid to insurance company	USD $366
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,219
Amount paid for insurance broker fees	197
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

GLTD0BLLM

Policy instance

Insurance contract or identification number	GLTD0BLLM
Number of Individuals Covered	112
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $1,880
Total amount of fees paid to insurance company	USD $1,250
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,880
Amount paid for insurance broker fees	1107
Additional information about fees paid to insurance broker	OTHER COMPENSATION ADMINISTRATION
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

616708D

Policy instance

Insurance contract or identification number	616708D
Number of Individuals Covered	35
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $204
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $204
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDS0BLLM

Policy instance

Insurance contract or identification number	GUDS0BLLM
Number of Individuals Covered	106
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $5,588
Total amount of fees paid to insurance company	USD $523
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,588
Amount paid for insurance broker fees	244
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

616708D

Policy instance

Insurance contract or identification number	616708D
Number of Individuals Covered	41
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $238
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $238
Insurance broker organization code?	3

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

43329000

Policy instance

Insurance contract or identification number	43329000
Number of Individuals Covered	125
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $22,050
Total amount of fees paid to insurance company	USD $10,566
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 $22,050
Amount paid for insurance broker fees	10566
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICES
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1080386

Policy instance

Insurance contract or identification number	1080386
Number of Individuals Covered	156
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $9,940
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $122,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,940
Insurance broker organization code?	3

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Company Name:	CZ-USA
Employer identification number (EIN):	770445408
NAIC Classification:	423910
NAIC Description:	Sporting and Recreational Goods and Supplies Merchant Wholesalers

Jurisdiction of Incorporation:	Nevada Department of State
Incorporation Date:	1997-01-06
Company Identification Number:	19971082177
Legal Registered Office Address:	2500 EAST SECOND STREET SUITE #29 RENO United States of America (USA) 89595