KIMBALL UNION ACADEMY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 126 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 128 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 129 |
| Number of employers contributing to the scheme | 2022-07-01 | 0 |
| 2021: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 121 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 122 |
| Number of employers contributing to the scheme | 2021-07-01 | 0 |
| 2020: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 119 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 115 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 117 |
| Number of employers contributing to the scheme | 2020-07-01 | 0 |
| 2019: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 116 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 117 |
| Number of employers contributing to the scheme | 2019-07-01 | 0 |
| 2018: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 111 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 111 |
| Number of employers contributing to the scheme | 2018-07-01 | 0 |
| 2017: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 117 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 113 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 7 |
| Total of all active and inactive participants | 2017-07-01 | 120 |
| 2016: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 111 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 4 |
| Total of all active and inactive participants | 2016-07-01 | 117 |
| 2015: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 111 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 0 |
| Total of all active and inactive participants | 2015-07-01 | 113 |
| 2014: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 104 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 102 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-07-01 | 0 |
| Total of all active and inactive participants | 2014-07-01 | 104 |
| 2013: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 73 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 71 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2013-07-01 | 2 |
| Total of all active and inactive participants | 2013-07-01 | 75 |
| 2012: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 86 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 71 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 19 |
| Number of other retired or separated participants entitled to future benefits | 2012-07-01 | 3 |
| Total of all active and inactive participants | 2012-07-01 | 93 |
| 2011: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 93 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 71 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 21 |
| Number of other retired or separated participants entitled to future benefits | 2011-07-01 | 6 |
| Total of all active and inactive participants | 2011-07-01 | 98 |
| 2010: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-07-01 | 65 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-07-01 | 70 |
| Number of retired or separated participants receiving benefits | 2010-07-01 | 22 |
| Number of other retired or separated participants entitled to future benefits | 2010-07-01 | 2 |
| Total of all active and inactive participants | 2010-07-01 | 94 |
| 2009: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 66 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 72 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 25 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 11 |
| Total of all active and inactive participants | 2009-07-01 | 108 |
| Total participants | 2009-07-01 | 0 |
| 2022: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-07-01 | Type of plan entity | Single employer plan |
| 2010-07-01 | Submission has been amended | No |
| 2010-07-01 | This submission is the final filing | No |
| 2010-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-07-01 | Plan is a collectively bargained plan | No |
| 2010-07-01 | Plan funding arrangement – Insurance | Yes |
| 2010-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: KIMBALL UNION ACADEMY WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWWX |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0AWWX | | Number of Individuals Covered | 126 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $4,040 | | Total amount of fees paid to insurance company | USD $2,394 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $41,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,040 | | Amount paid for insurance broker fees | 2394 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 302385 |
| Policy instance | 3 |
| Insurance contract or identification number | 302385 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $117 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $117 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 4 |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 2 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $1,714 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,250 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,714 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 3599 |
| Policy instance | 1 |
| Insurance contract or identification number | 3599 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $8,082 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $129,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,458 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 2 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $1,560 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,707 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,560 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 302385 |
| Policy instance | 3 |
| Insurance contract or identification number | 302385 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $127 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $127 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWWX |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0AWWX | | Number of Individuals Covered | 119 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $4,040 | | Total amount of fees paid to insurance company | USD $1,623 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $37,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,040 | | Amount paid for insurance broker fees | 1623 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 3599 |
| Policy instance | 1 |
| Insurance contract or identification number | 3599 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $7,624 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $123,571 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,102 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWWX |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AWWX | | Number of Individuals Covered | 113 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $4,040 | | Total amount of fees paid to insurance company | USD $2,105 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $34,847 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,040 | | Amount paid for insurance broker fees | 2105 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 2 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $1,055 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,683 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,055 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 3599 |
| Policy instance | 1 |
| Insurance contract or identification number | 3599 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $6,933 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $100,820 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,571 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 2 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $1,147 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,147 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 3599 |
| Policy instance | 1 |
| Insurance contract or identification number | 3599 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $6,965 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $112,849 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,605 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWWX |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AWWX | | Number of Individuals Covered | 115 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $4,040 | | Total amount of fees paid to insurance company | USD $2,068 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $34,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,040 | | Amount paid for insurance broker fees | 2068 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 3599 |
| Policy instance | 1 |
| Insurance contract or identification number | 3599 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $6,170 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $101,149 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,048 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 2 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $204 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,039 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $204 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWWX |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AWWX | | Number of Individuals Covered | 114 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $4,040 | | Total amount of fees paid to insurance company | USD $2,076 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $35,146 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,040 | | Amount paid for insurance broker fees | 2076 | | 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 | GVLT0AWWX |
| Policy instance | 2 |
| Insurance contract or identification number | GVLT0AWWX | | Number of Individuals Covered | 23 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,000 | | Total amount of fees paid to insurance company | USD $464 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,061 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,000 | | Amount paid for insurance broker fees | 464 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 3599 |
| Policy instance | 1 |
| Insurance contract or identification number | 3599 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $6,236 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $101,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,040 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | COMBINED SERVICES LLC |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 3 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,109 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,109 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWWX |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0AWWX | | Number of Individuals Covered | 113 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,000 | | Total amount of fees paid to insurance company | USD $648 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $11,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,000 | | Amount paid for insurance broker fees | 648 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD00AWWX |
| Policy instance | 5 |
| Insurance contract or identification number | GLTD00AWWX | | Number of Individuals Covered | 113 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $2,040 | | Total amount of fees paid to insurance company | USD $853 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,783 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,040 | | Amount paid for insurance broker fees | 853 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWWX |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AWWX | | Number of Individuals Covered | 111 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $4,040 | | Total amount of fees paid to insurance company | USD $543 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,040 | | Amount paid for insurance broker fees | 543 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 3599 |
| Policy instance | 1 |
| Insurance contract or identification number | 3599 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $5,910 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $94,550 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,748 | | Insurance broker organization code? | 3 | | Insurance broker name | COMBINED SERVICES, LLC |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 2 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $941 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $941 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10104539 |
| Policy instance | 3 |
| Insurance contract or identification number | 10104539 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $4,140 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $33,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,140 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 2 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,329 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,060 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,329 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 3599 |
| Policy instance | 1 |
| Insurance contract or identification number | 3599 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $5,820 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $94,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,689 | | Insurance broker organization code? | 3 | | Insurance broker name | COMBINED SERVICES, LLC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010104540 |
| Policy instance | 9 |
| Insurance contract or identification number | 000010104540 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $1,896 | | Total amount of fees paid to insurance company | USD $366 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,642 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,896 | | Amount paid for insurance broker fees | 366 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| HR CONCEPTS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | FSA DCA |
| Policy instance | 1 |
| Insurance contract or identification number | FSA DCA | | Number of Individuals Covered | 33 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $78 | | Total amount of fees paid to insurance company | USD $1,310 | | Other welfare benefits provided | FSA DCA | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $78 | | Amount paid for insurance broker fees | 1310 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEE | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057463 |
| Policy instance | 12 |
| Insurance contract or identification number | 057463 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $9,096 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | HRA/HSA PLAN | | Welfare Benefit Premiums Paid to Carrier | USD $277,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,096 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 000003599 |
| Policy instance | 11 |
| Insurance contract or identification number | 000003599 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $5,259 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $85,497 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,045 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| ANTHEM HEALTH PLANS OF NEW HAMPSHIRE, INC. (National Association of Insurance Commissioners NAIC id number: 53759 ) |
| Policy contract number | 364037 |
| Policy instance | 10 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $542 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $542 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 |
| Policy instance | 8 |
| Insurance contract or identification number | 000400001000 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $411 | | Total amount of fees paid to insurance company | USD $124 | | Other welfare benefits provided | VOL LIFE, VOL SPOUSE LIFE, VOL CHILD LIFE, VOL AD&D, VOL SPOUSE AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $4,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $411 | | Amount paid for insurance broker fees | 124 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| HR CONCEPTS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | HRA 2 PERSON |
| Policy instance | 7 |
| Insurance contract or identification number | HRA 2 PERSON | | Number of Individuals Covered | 54 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $78 | | Total amount of fees paid to insurance company | USD $3,708 | | Other welfare benefits provided | HRA 2-PERSON/FAMILY | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $78 | | Amount paid for insurance broker fees | 3708 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE |
|
| HR CONCEPTS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | HRA SINGLE |
| Policy instance | 6 |
| Insurance contract or identification number | HRA SINGLE | | Number of Individuals Covered | 25 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | HRA SINGLE | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010104539 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010104539 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $1,576 | | Total amount of fees paid to insurance company | USD $405 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $14,578 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,576 | | Amount paid for insurance broker fees | 405 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 083755 |
| Policy instance | 4 |
| Insurance contract or identification number | 083755 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $1,223 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,530 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,223 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY |
|
| HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 ) |
| Policy contract number | 083803 |
| Policy instance | 3 |
| Insurance contract or identification number | 083803 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $12,504 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | HRA | | Welfare Benefit Premiums Paid to Carrier | USD $452,421 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,504 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY |
|
| HR CONCEPTS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | HRA CARRYOVER |
| Policy instance | 2 |
| Insurance contract or identification number | HRA CARRYOVER | | Number of Individuals Covered | 37 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | HRA CARRYOVER | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057467 |
| Policy instance | 5 |
| Insurance contract or identification number | 057467 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $2,527 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,731 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,527 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010104540 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010104540 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,680 | | Total amount of fees paid to insurance company | USD $559 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,199 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,680 | | Amount paid for insurance broker fees | 559 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000400001000 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $360 | | Total amount of fees paid to insurance company | USD $254 | | Other welfare benefits provided | VOL LIFE, VOL SPOUSE LIFE, VOL CHILD LIFE, VOL AD&D, VOL SPOUSE AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $3,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $360 | | Amount paid for insurance broker fees | 254 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010104539 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010104539 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,339 | | Total amount of fees paid to insurance company | USD $624 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,613 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,339 | | Amount paid for insurance broker fees | 624 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
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| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057787 |
| Policy instance | 1 |
| Insurance contract or identification number | 057787 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $73 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,454 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $73 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY |
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| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 364037 |
| Policy instance | 6 |
| Insurance contract or identification number | 364037 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $976 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $976 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 000003599 |
| Policy instance | 7 |
| Insurance contract or identification number | 000003599 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $4,595 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,931 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $893 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER A. BORISLOW INS AGENCY INC |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057463 |
| Policy instance | 8 |
| Insurance contract or identification number | 057463 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $17,766 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | HRA PLAN | | Welfare Benefit Premiums Paid to Carrier | USD $596,110 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,766 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057787 |
| Policy instance | 1 |
| Insurance contract or identification number | 057787 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $41 | | Total amount of fees paid to insurance company | USD $24 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010104539 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010104539 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $1,302 | | Total amount of fees paid to insurance company | USD $670 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,150 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000400001000 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $376 | | Total amount of fees paid to insurance company | USD $183 | | Other welfare benefits provided | VOL LIFE, VOL SPOUSE LIFE, VOL CHILD LIFE, VOL AD&D, VOL SPOUSE AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $3,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 000003599 |
| Policy instance | 7 |
| Insurance contract or identification number | 000003599 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $4,570 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,334 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010104540 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010104540 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $1,576 | | Total amount of fees paid to insurance company | USD $582 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057467 |
| Policy instance | 5 |
| Insurance contract or identification number | 057467 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $2,739 | | Total amount of fees paid to insurance company | USD $976 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | NS3542-V006 |
| Policy instance | 6 |
| Insurance contract or identification number | NS3542-V006 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $437 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057463 |
| Policy instance | 8 |
| Insurance contract or identification number | 057463 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $15,689 | | Total amount of fees paid to insurance company | USD $5,743 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | HRA PLAN | | Welfare Benefit Premiums Paid to Carrier | USD $570,719 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057467 |
| Policy instance | 5 |
| Insurance contract or identification number | 057467 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $3,007 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,928 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | NS3542-V006 |
| Policy instance | 6 |
| Insurance contract or identification number | NS3542-V006 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $1,072 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000400001000 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $567 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOL LIFE, VOL SPOUSE LIFE, VOL CHILD LIFE, VOL AD&D, VOL SPOUSE AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,673 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057463 |
| Policy instance | 8 |
| Insurance contract or identification number | 057463 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $18,286 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | HRA PLAN | | Welfare Benefit Premiums Paid to Carrier | USD $562,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 ) |
| Policy contract number | 057787 |
| Policy instance | 1 |
| Insurance contract or identification number | 057787 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $543 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,107 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010104539 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010104539 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $1,519 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NORTHEAST DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 47079 ) |
| Policy contract number | 000003599 |
| Policy instance | 7 |
| Insurance contract or identification number | 000003599 | | Number of Individuals Covered | 173 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $4,427 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010104540 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010104540 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $1,766 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,775 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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