COLLUMS ADMINISTRATION AND MAINTENANCE CO LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN
401k plan membership statisitcs for COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN
| Measure | Date | Value |
|---|
| 2017 : COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2017 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2017-11-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-11-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-11-30 | $0 |
| Total income from all sources (including contributions) | 2017-11-30 | $1,779,338 |
| Total loss/gain on sale of assets | 2017-11-30 | $0 |
| Total of all expenses incurred | 2017-11-30 | $1,745,132 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-11-30 | $1,646,745 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-11-30 | $1,779,338 |
| Value of total assets at end of year | 2017-11-30 | $110,093 |
| Value of total assets at beginning of year | 2017-11-30 | $75,887 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-11-30 | $98,387 |
| Total interest from all sources | 2017-11-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-11-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-11-30 | No |
| Was this plan covered by a fidelity bond | 2017-11-30 | Yes |
| Value of fidelity bond cover | 2017-11-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2017-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-11-30 | No |
| Contributions received from participants | 2017-11-30 | $673,747 |
| Participant contributions at end of year | 2017-11-30 | $22,055 |
| Participant contributions at beginning of year | 2017-11-30 | $6,734 |
| Total non interest bearing cash at end of year | 2017-11-30 | $88,038 |
| Total non interest bearing cash at beginning of year | 2017-11-30 | $24,917 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-11-30 | No |
| Value of net income/loss | 2017-11-30 | $34,206 |
| Value of net assets at end of year (total assets less liabilities) | 2017-11-30 | $110,093 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-11-30 | $75,887 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-11-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-11-30 | $355,186 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-11-30 | No |
| Contributions received in cash from employer | 2017-11-30 | $1,105,591 |
| Employer contributions (assets) at beginning of year | 2017-11-30 | $44,236 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-11-30 | $1,291,559 |
| Contract administrator fees | 2017-11-30 | $98,387 |
| Did the plan have assets held for investment | 2017-11-30 | 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 | 2017-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-11-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-11-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-11-30 | Unqualified |
| Accountancy firm name | 2017-11-30 | SCOTT AND COMPANY, LLC |
| Accountancy firm EIN | 2017-11-30 | 571021392 |
| 2016 : COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2016 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2016-11-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-11-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-11-30 | $0 |
| Total income from all sources (including contributions) | 2016-11-30 | $1,637,117 |
| Total loss/gain on sale of assets | 2016-11-30 | $0 |
| Total of all expenses incurred | 2016-11-30 | $1,665,335 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-11-30 | $1,514,659 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-11-30 | $1,637,117 |
| Value of total assets at end of year | 2016-11-30 | $75,887 |
| Value of total assets at beginning of year | 2016-11-30 | $104,105 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-11-30 | $150,676 |
| Total interest from all sources | 2016-11-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-11-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-11-30 | No |
| Was this plan covered by a fidelity bond | 2016-11-30 | Yes |
| Value of fidelity bond cover | 2016-11-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2016-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-11-30 | No |
| Contributions received from participants | 2016-11-30 | $492,731 |
| Participant contributions at end of year | 2016-11-30 | $6,734 |
| Participant contributions at beginning of year | 2016-11-30 | $10,481 |
| Total non interest bearing cash at end of year | 2016-11-30 | $24,917 |
| Total non interest bearing cash at beginning of year | 2016-11-30 | $2,170 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-11-30 | No |
| Value of net income/loss | 2016-11-30 | $-28,218 |
| Value of net assets at end of year (total assets less liabilities) | 2016-11-30 | $75,887 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-11-30 | $104,105 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-11-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-11-30 | $186,201 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-11-30 | No |
| Contributions received in cash from employer | 2016-11-30 | $1,144,386 |
| Employer contributions (assets) at end of year | 2016-11-30 | $44,236 |
| Employer contributions (assets) at beginning of year | 2016-11-30 | $91,454 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-11-30 | $1,328,458 |
| Contract administrator fees | 2016-11-30 | $150,676 |
| Did the plan have assets held for investment | 2016-11-30 | 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 | 2016-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-11-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-11-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2016-11-30 | Unqualified |
| Accountancy firm name | 2016-11-30 | THOMAS, WATSON & DYCHES, LLC |
| Accountancy firm EIN | 2016-11-30 | 743188333 |
| 2015 : COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-11-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-11-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-11-30 | $0 |
| Total income from all sources (including contributions) | 2015-11-30 | $1,192,977 |
| Total loss/gain on sale of assets | 2015-11-30 | $0 |
| Total of all expenses incurred | 2015-11-30 | $1,142,722 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-11-30 | $1,026,245 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-11-30 | $1,192,977 |
| Value of total assets at end of year | 2015-11-30 | $104,105 |
| Value of total assets at beginning of year | 2015-11-30 | $53,850 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-11-30 | $116,477 |
| Total interest from all sources | 2015-11-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-11-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-11-30 | No |
| Was this plan covered by a fidelity bond | 2015-11-30 | Yes |
| Value of fidelity bond cover | 2015-11-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2015-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-11-30 | No |
| Contributions received from participants | 2015-11-30 | $454,474 |
| Participant contributions at end of year | 2015-11-30 | $10,481 |
| Participant contributions at beginning of year | 2015-11-30 | $8,018 |
| Total non interest bearing cash at end of year | 2015-11-30 | $2,170 |
| Total non interest bearing cash at beginning of year | 2015-11-30 | $9,569 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-11-30 | No |
| Value of net income/loss | 2015-11-30 | $50,255 |
| Value of net assets at end of year (total assets less liabilities) | 2015-11-30 | $104,105 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-11-30 | $53,850 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-11-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-11-30 | $180,131 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-11-30 | No |
| Contributions received in cash from employer | 2015-11-30 | $738,503 |
| Employer contributions (assets) at end of year | 2015-11-30 | $91,454 |
| Employer contributions (assets) at beginning of year | 2015-11-30 | $36,263 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-11-30 | $846,114 |
| Contract administrator fees | 2015-11-30 | $116,477 |
| Did the plan have assets held for investment | 2015-11-30 | 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 | 2015-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-11-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-11-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-11-30 | Unqualified |
| Accountancy firm name | 2015-11-30 | THOMAS, WATSON & DYCHES, LLC |
| Accountancy firm EIN | 2015-11-30 | 743188333 |
| 2014 : COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-11-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-11-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-11-30 | $0 |
| Total income from all sources (including contributions) | 2014-11-30 | $894,647 |
| Total loss/gain on sale of assets | 2014-11-30 | $0 |
| Total of all expenses incurred | 2014-11-30 | $952,962 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-11-30 | $852,986 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-11-30 | $894,647 |
| Value of total assets at end of year | 2014-11-30 | $53,850 |
| Value of total assets at beginning of year | 2014-11-30 | $112,165 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-11-30 | $99,976 |
| Total interest from all sources | 2014-11-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-11-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-11-30 | No |
| Was this plan covered by a fidelity bond | 2014-11-30 | Yes |
| Value of fidelity bond cover | 2014-11-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2014-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-11-30 | No |
| Contributions received from participants | 2014-11-30 | $433,642 |
| Participant contributions at end of year | 2014-11-30 | $8,018 |
| Participant contributions at beginning of year | 2014-11-30 | $8,070 |
| Total non interest bearing cash at end of year | 2014-11-30 | $9,569 |
| Total non interest bearing cash at beginning of year | 2014-11-30 | $34,986 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-11-30 | No |
| Value of net income/loss | 2014-11-30 | $-58,315 |
| Value of net assets at end of year (total assets less liabilities) | 2014-11-30 | $53,850 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-11-30 | $112,165 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-11-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-11-30 | $161,733 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-11-30 | No |
| Contributions received in cash from employer | 2014-11-30 | $461,005 |
| Employer contributions (assets) at end of year | 2014-11-30 | $36,263 |
| Employer contributions (assets) at beginning of year | 2014-11-30 | $69,109 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-11-30 | $691,253 |
| Contract administrator fees | 2014-11-30 | $99,976 |
| Did the plan have assets held for investment | 2014-11-30 | 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 | 2014-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-11-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-11-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-11-30 | Unqualified |
| Accountancy firm name | 2014-11-30 | THOMAS, WATSON & DYCHES, LLC |
| Accountancy firm EIN | 2014-11-30 | 743188333 |
| 2013 : COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-11-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-11-30 | $112,165 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-11-30 | $88,042 |
| Total income from all sources (including contributions) | 2013-11-30 | $1,400,448 |
| Total loss/gain on sale of assets | 2013-11-30 | $0 |
| Total of all expenses incurred | 2013-11-30 | $1,376,325 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-11-30 | $1,238,850 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-11-30 | $1,400,448 |
| Value of total assets at end of year | 2013-11-30 | $112,165 |
| Value of total assets at beginning of year | 2013-11-30 | $88,042 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-11-30 | $137,475 |
| Total interest from all sources | 2013-11-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-11-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-11-30 | No |
| Was this plan covered by a fidelity bond | 2013-11-30 | Yes |
| Value of fidelity bond cover | 2013-11-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2013-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-11-30 | No |
| Contributions received from participants | 2013-11-30 | $414,906 |
| Participant contributions at end of year | 2013-11-30 | $8,070 |
| Participant contributions at beginning of year | 2013-11-30 | $0 |
| Total non interest bearing cash at end of year | 2013-11-30 | $34,986 |
| Total non interest bearing cash at beginning of year | 2013-11-30 | $4,260 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-11-30 | No |
| Value of net income/loss | 2013-11-30 | $24,123 |
| Value of net assets at end of year (total assets less liabilities) | 2013-11-30 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-11-30 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-11-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-11-30 | $155,384 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-11-30 | No |
| Contributions received in cash from employer | 2013-11-30 | $985,542 |
| Employer contributions (assets) at end of year | 2013-11-30 | $69,109 |
| Employer contributions (assets) at beginning of year | 2013-11-30 | $83,782 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-11-30 | $1,083,466 |
| Contract administrator fees | 2013-11-30 | $137,475 |
| Liabilities. Value of benefit claims payable at end of year | 2013-11-30 | $112,165 |
| Liabilities. Value of benefit claims payable at beginning of year | 2013-11-30 | $88,042 |
| Did the plan have assets held for investment | 2013-11-30 | 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 | 2013-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-11-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-11-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-11-30 | Unqualified |
| Accountancy firm name | 2013-11-30 | THOMAS, WATSON & DYCHES, LLC |
| Accountancy firm EIN | 2013-11-30 | 743188333 |
| 2012 : COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2012 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-11-30 | $88,042 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-11-30 | $64,132 |
| Total income from all sources (including contributions) | 2012-11-30 | $1,052,055 |
| Total of all expenses incurred | 2012-11-30 | $1,012,494 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-11-30 | $900,605 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-11-30 | $1,052,055 |
| Value of total assets at end of year | 2012-11-30 | $88,042 |
| Value of total assets at beginning of year | 2012-11-30 | $64,132 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-11-30 | $111,889 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-11-30 | No |
| Was this plan covered by a fidelity bond | 2012-11-30 | Yes |
| Value of fidelity bond cover | 2012-11-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2012-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-11-30 | No |
| Contributions received from participants | 2012-11-30 | $488,627 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2012-11-30 | $15,651 |
| Total non interest bearing cash at end of year | 2012-11-30 | $4,260 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-11-30 | No |
| Value of net income/loss | 2012-11-30 | $39,561 |
| Value of net assets at end of year (total assets less liabilities) | 2012-11-30 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-11-30 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-11-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-11-30 | $183,176 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-11-30 | No |
| Contributions received in cash from employer | 2012-11-30 | $563,428 |
| Employer contributions (assets) at end of year | 2012-11-30 | $83,782 |
| Employer contributions (assets) at beginning of year | 2012-11-30 | $64,132 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-11-30 | $717,429 |
| Contract administrator fees | 2012-11-30 | $111,889 |
| 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 | 2012-11-30 | No |
| Liabilities. Value of benefit claims payable at end of year | 2012-11-30 | $88,042 |
| Liabilities. Value of benefit claims payable at beginning of year | 2012-11-30 | $48,481 |
| Did the plan have assets held for investment | 2012-11-30 | 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 | 2012-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-11-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-11-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-11-30 | Unqualified |
| Accountancy firm name | 2012-11-30 | KIRKLAND, THOMAS, WATSON & DYCHES |
| Accountancy firm EIN | 2012-11-30 | 743188333 |
| 2011 : COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2011 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-11-30 | $64,132 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-11-30 | $171,266 |
| Total income from all sources (including contributions) | 2011-11-30 | $1,041,919 |
| Total of all expenses incurred | 2011-11-30 | $1,041,919 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-11-30 | $955,927 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-11-30 | $1,041,919 |
| Value of total assets at end of year | 2011-11-30 | $64,132 |
| Value of total assets at beginning of year | 2011-11-30 | $171,266 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-11-30 | $85,992 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-11-30 | No |
| Was this plan covered by a fidelity bond | 2011-11-30 | Yes |
| Value of fidelity bond cover | 2011-11-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2011-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-11-30 | No |
| Contributions received from participants | 2011-11-30 | $435,639 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2011-11-30 | $15,651 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2011-11-30 | $13,089 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-11-30 | No |
| Value of net income/loss | 2011-11-30 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2011-11-30 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-11-30 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-11-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-11-30 | $258,925 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-11-30 | No |
| Contributions received in cash from employer | 2011-11-30 | $606,280 |
| Employer contributions (assets) at end of year | 2011-11-30 | $64,132 |
| Employer contributions (assets) at beginning of year | 2011-11-30 | $171,266 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-11-30 | $697,002 |
| Contract administrator fees | 2011-11-30 | $85,992 |
| Liabilities. Value of benefit claims payable at end of year | 2011-11-30 | $48,481 |
| Liabilities. Value of benefit claims payable at beginning of year | 2011-11-30 | $158,177 |
| Did the plan have assets held for investment | 2011-11-30 | 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 | 2011-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-11-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-11-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-11-30 | Unqualified |
| Accountancy firm name | 2011-11-30 | KIRKLAND, THOMAS, WATSON, & DYCHES |
| Accountancy firm EIN | 2011-11-30 | 743188333 |
| 2021: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2021 form 5500 responses |
|---|
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Submission has been amended | No |
| 2021-12-01 | This submission is the final filing | No |
| 2021-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-12-01 | Plan is a collectively bargained plan | No |
| 2021-12-01 | Plan funding arrangement – Insurance | Yes |
| 2021-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | First time form 5500 has been submitted | Yes |
| 2020-12-01 | Submission has been amended | No |
| 2020-12-01 | This submission is the final filing | No |
| 2020-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-12-01 | Plan is a collectively bargained plan | No |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Submission has been amended | Yes |
| 2019-12-01 | This submission is the final filing | No |
| 2019-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-12-01 | Plan is a collectively bargained plan | No |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Submission has been amended | No |
| 2018-12-01 | This submission is the final filing | No |
| 2018-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-12-01 | Plan is a collectively bargained plan | No |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Submission has been amended | No |
| 2016-12-01 | This submission is the final filing | No |
| 2016-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-12-01 | Plan is a collectively bargained plan | No |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan funding arrangement – Trust | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement - Trust | Yes |
| 2015: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan funding arrangement – Trust | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement - Trust | Yes |
| 2014: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | Submission has been amended | No |
| 2014-12-01 | This submission is the final filing | No |
| 2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-01 | Plan is a collectively bargained plan | No |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan funding arrangement – Trust | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement - Trust | Yes |
| 2013: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2013 form 5500 responses |
|---|
| 2013-12-01 | Type of plan entity | Single employer plan |
| 2013-12-01 | Submission has been amended | No |
| 2013-12-01 | This submission is the final filing | No |
| 2013-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-12-01 | Plan is a collectively bargained plan | No |
| 2013-12-01 | Plan funding arrangement – Insurance | Yes |
| 2013-12-01 | Plan funding arrangement – Trust | Yes |
| 2013-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-12-01 | Plan benefit arrangement - Trust | Yes |
| 2012: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Submission has been amended | No |
| 2012-12-01 | This submission is the final filing | No |
| 2012-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-12-01 | Plan is a collectively bargained plan | No |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan funding arrangement – Trust | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement - Trust | Yes |
| 2011: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2011 form 5500 responses |
|---|
| 2011-12-01 | Type of plan entity | Single employer plan |
| 2011-12-01 | Submission has been amended | No |
| 2011-12-01 | This submission is the final filing | No |
| 2011-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-12-01 | Plan is a collectively bargained plan | No |
| 2011-12-01 | Plan funding arrangement – Insurance | Yes |
| 2011-12-01 | Plan funding arrangement – Trust | Yes |
| 2011-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-12-01 | Plan benefit arrangement - Trust | Yes |
| 2010: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2010 form 5500 responses |
|---|
| 2010-12-01 | Type of plan entity | Single employer plan |
| 2010-12-01 | Submission has been amended | No |
| 2010-12-01 | This submission is the final filing | No |
| 2010-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-12-01 | Plan is a collectively bargained plan | No |
| 2010-12-01 | Plan funding arrangement – Insurance | Yes |
| 2010-12-01 | Plan funding arrangement – Trust | Yes |
| 2010-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-12-01 | Plan benefit arrangement - Trust | Yes |
| 2009: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2009 form 5500 responses |
|---|
| 2009-12-01 | Type of plan entity | Single employer plan |
| 2009-12-01 | Submission has been amended | No |
| 2009-12-01 | This submission is the final filing | No |
| 2009-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-12-01 | Plan is a collectively bargained plan | No |
| 2009-12-01 | Plan funding arrangement – Insurance | Yes |
| 2009-12-01 | Plan funding arrangement – Trust | Yes |
| 2009-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-12-01 | Plan benefit arrangement - Trust | Yes |
| 2008: COLLUM'S ADMINISTRATION AND MAINTENANCE, LLC GROUP MEDICAL & DENTAL PLAN 2008 form 5500 responses |
|---|
| 2008-12-01 | Type of plan entity | Single employer plan |
| 2008-12-01 | First time form 5500 has been submitted | Yes |
| 2008-12-01 | Submission has been amended | No |
| 2008-12-01 | This submission is the final filing | No |
| 2008-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-12-01 | Plan is a collectively bargained plan | No |
| 2008-12-01 | Plan funding arrangement – Insurance | Yes |
| 2008-12-01 | Plan funding arrangement – Trust | Yes |
| 2008-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2008-12-01 | Plan benefit arrangement - Trust | Yes |
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-040980 |
| Policy instance | 8 |
| Insurance contract or identification number | 010-040980 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $1,341 | | Total amount of fees paid to insurance company | USD $423 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,341 | | Amount paid for insurance broker fees | 423 | | 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 | G000AT5S |
| Policy instance | 1 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 77 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $3,467 | | Total amount of fees paid to insurance company | USD $2,194 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOL SHORT TERM DISABILITY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,343 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $347 | | Amount paid for insurance broker fees | 2194 | | 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 | G000AT5S |
| Policy instance | 2 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 61 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $5,674 | | Total amount of fees paid to insurance company | USD $1,730 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY TERM 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 $29,865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,674 | | Amount paid for insurance broker fees | 1730 | | 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 | G000AT5S |
| Policy instance | 3 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 170 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $1,942 | | Total amount of fees paid to insurance company | USD $788 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $12,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,942 | | Amount paid for insurance broker fees | 788 | | 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 | G000AT5S |
| Policy instance | 4 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 171 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $6,975 | | Total amount of fees paid to insurance company | USD $2,528 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $46,503 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,975 | | Amount paid for insurance broker fees | 2528 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 ) |
| Policy contract number | 06405 |
| Policy instance | 5 |
| Insurance contract or identification number | 06405 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLI-SUM20212-02 |
| Policy instance | 6 |
| Insurance contract or identification number | CLI-SUM20212-02 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 ) |
| Policy contract number | 03-07686 |
| Policy instance | 7 |
| Insurance contract or identification number | 03-07686 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 2 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 174 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $7,109 | | Total amount of fees paid to insurance company | USD $1,995 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $47,396 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1995 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $7,109 | | Other welfare benefits provided | AD&D |
|
| BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 ) |
| Policy contract number | 06405 |
| Policy instance | 3 |
| Insurance contract or identification number | 06405 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 4 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 81 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $3,530 | | Total amount of fees paid to insurance company | USD $1,517 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SHORT TERM DISABILITY | | 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 $40,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1517 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $353 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 5 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 71 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $6,177 | | Total amount of fees paid to insurance company | USD $1,578 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | TERM LIFE - VOLUNTARY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1578 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $6,177 |
|
| BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 ) |
| Policy contract number | 03-07686 |
| Policy instance | 6 |
| Insurance contract or identification number | 03-07686 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 7 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 173 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $2,241 | | Total amount of fees paid to insurance company | USD $678 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,937 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 678 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $2,241 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-040980 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-040980 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $1,363 | | Total amount of fees paid to insurance company | USD $437 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Amount paid for insurance broker fees | 437 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $1,363 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-040980 |
| Policy instance | 7 |
| Insurance contract or identification number | 010-040980 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $1,363 | | Total amount of fees paid to insurance company | USD $437 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 ) |
| Policy contract number | 06405 |
| Policy instance | 6 |
| Insurance contract or identification number | 06405 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 ) |
| Policy contract number | 03-07686 |
| Policy instance | 5 |
| Insurance contract or identification number | 03-07686 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 3 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 81 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $3,530 | | Total amount of fees paid to insurance company | USD $1,517 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SHORT TERM DISABILITY | | 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 $40,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 1 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 174 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $7,109 | | Total amount of fees paid to insurance company | USD $1,995 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $47,396 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 1 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 88 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $3,413 | | Total amount of fees paid to insurance company | USD $3,505 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,262 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,413 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2357 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-040980 |
| Policy instance | 6 |
| Insurance contract or identification number | 010-040980 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,443 | | Total amount of fees paid to insurance company | USD $487 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,431 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 487 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $1,443 |
|
| BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 ) |
| Policy contract number | 06405 |
| Policy instance | 5 |
| Insurance contract or identification number | 06405 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $60,392 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 4 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 92 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $7,532 | | Total amount of fees paid to insurance company | USD $3,415 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | TERM LIFE - VOLUNTARY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,643 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2226 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $7,532 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 3 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 88 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $3,413 | | Total amount of fees paid to insurance company | USD $3,505 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,262 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2357 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $3,413 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 6 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 92 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $7,532 | | Total amount of fees paid to insurance company | USD $3,415 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | TERM LIFE - VOLUNTARY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,643 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2226 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $7,532 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 5 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 223 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $7,484 | | Total amount of fees paid to insurance company | USD $4,440 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $49,892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2943 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $7,484 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-040980 |
| Policy instance | 4 |
| Insurance contract or identification number | 010-040980 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,443 | | Total amount of fees paid to insurance company | USD $487 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,431 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 487 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $1,443 |
|
| BLUECHOICE HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 95741 ) |
| Policy contract number | 06405 |
| Policy instance | 3 |
| Insurance contract or identification number | 06405 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $60,392 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 2 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 223 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $2,541 | | Total amount of fees paid to insurance company | USD $1,547 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $16,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1039 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $2,541 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 25774 |
| Policy instance | 8 |
| Insurance contract or identification number | 25774 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $2,022 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,901 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,115 | | Insurance broker organization code? | 5 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 25774 |
| Policy instance | 7 |
| Insurance contract or identification number | 25774 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $2,392 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,194 | | Insurance broker organization code? | 5 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-040980 |
| Policy instance | 6 |
| Insurance contract or identification number | 010-040980 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-12-01 | | Total amount of commissions paid to insurance broker | USD $1,722 | | Total amount of fees paid to insurance company | USD $500 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 500 | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $1,722 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18812 |
| Policy instance | 5 |
| Insurance contract or identification number | HCL18812 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $8,234 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,234 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 4 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 97 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $7,015 | | Total amount of fees paid to insurance company | USD $3,239 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | TERM LIFE - VOLUNTARY | | 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 $36,923 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2131 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Commission paid to Insurance Broker | USD $7,015 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 3 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 97 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $3,412 | | Total amount of fees paid to insurance company | USD $2,790 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,412 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1643 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 2 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 230 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $7,207 | | Total amount of fees paid to insurance company | USD $4,018 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $48,045 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2577 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $7,207 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 25774 |
| Policy instance | 9 |
| Insurance contract or identification number | 25774 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $1,785 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,999 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $910 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 1 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 230 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $2,577 | | Total amount of fees paid to insurance company | USD $1,567 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $17,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1047 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $2,577 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 25774 |
| Policy instance | 1 |
| Insurance contract or identification number | 25774 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $769 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $6,872 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 25774 |
| Policy instance | 9 |
| Insurance contract or identification number | 25774 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $999 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $8,516 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 8 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 96 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $6,702 | | Total amount of fees paid to insurance company | USD $2,380 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $35,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 7 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 259 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $6,521 | | Total amount of fees paid to insurance company | USD $3,017 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,472 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 6 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 81 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $2,718 | | Total amount of fees paid to insurance company | USD $1,824 | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $27,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT5S |
| Policy instance | 5 |
| Insurance contract or identification number | G000AT5S | | Number of Individuals Covered | 259 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $2,648 | | Total amount of fees paid to insurance company | USD $1,221 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $17,655 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-040980 |
| Policy instance | 4 |
| Insurance contract or identification number | 010-040980 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $1,600 | | Total amount of fees paid to insurance company | USD $453 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 25774 |
| Policy instance | 2 |
| Insurance contract or identification number | 25774 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $1,189 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,674 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18812 |
| Policy instance | 3 |
| Insurance contract or identification number | HCL18812 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $3,045 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
