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GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameGORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN
Plan identification number 504

GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

GORDON BROTHERS GROUP LLC has sponsored the creation of one or more 401k plans.

Company Name:GORDON BROTHERS GROUP LLC
Employer identification number (EIN):043403041
NAIC Classification:541990
NAIC Description:All Other Professional, Scientific, and Technical Services

Additional information about GORDON BROTHERS GROUP LLC

Jurisdiction of Incorporation: Georgia Department of States Corporations Division
Incorporation Date:
Company Identification Number: 2143342

More information about GORDON BROTHERS GROUP LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5042022-01-01JEN HAMEDANY2023-06-01
5042021-01-01JEN HAMEDANY2022-07-06
5042020-01-01KARIN SPYCHALSKI2021-07-01
5042019-01-01KARIN SPYCHALSKI2020-06-09
5042018-01-01
5042017-01-01

Plan Statistics for GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN

Measure Date Value
2022: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01206
Total number of active participants reported on line 7a of the Form 55002022-01-01210
Number of retired or separated participants receiving benefits2022-01-0112
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01222
Number of employers contributing to the scheme2022-01-010
2021: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01206
Total number of active participants reported on line 7a of the Form 55002021-01-01203
Number of retired or separated participants receiving benefits2021-01-013
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01206
Number of employers contributing to the scheme2021-01-010
2020: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01198
Total number of active participants reported on line 7a of the Form 55002020-01-01203
Number of retired or separated participants receiving benefits2020-01-013
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01206
Number of employers contributing to the scheme2020-01-010
2019: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01204
Total number of active participants reported on line 7a of the Form 55002019-01-01191
Number of retired or separated participants receiving benefits2019-01-017
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01198
Number of employers contributing to the scheme2019-01-010
2018: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01191
Total number of active participants reported on line 7a of the Form 55002018-01-01198
Number of retired or separated participants receiving benefits2018-01-016
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01204
Number of employers contributing to the scheme2018-01-010
2017: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01190
Total number of active participants reported on line 7a of the Form 55002017-01-01188
Number of retired or separated participants receiving benefits2017-01-013
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01191

Form 5500 Responses for GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN

2022: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: GORDON BROTHERS GROUP LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01First time form 5500 has been submittedYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK604977
Policy instance 5
Insurance contract or identification numberSOK604977
Number of Individuals Covered210
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,169
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $91,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees1169
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number13856
Policy instance 4
Insurance contract or identification number13856
Number of Individuals Covered433
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $9,018
Total amount of fees paid to insurance companyUSD $1,416
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $245,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,018
Amount paid for insurance broker fees1416
Additional information about fees paid to insurance brokerOTHER FEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10028661001
Policy instance 3
Insurance contract or identification number10028661001
Number of Individuals Covered381
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ALLONE HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 2
Insurance contract or identification number00
Number of Individuals Covered209
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $10,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4953349
Policy instance 1
Insurance contract or identification number4953349
Number of Individuals Covered431
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $66,002
Total amount of fees paid to insurance companyUSD $18,400
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $66,002
Amount paid for insurance broker fees18400
Additional information about fees paid to insurance brokerOTHER COMMISSION
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4953349
Policy instance 1
Insurance contract or identification number4953349
Number of Individuals Covered420
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $62,383
Total amount of fees paid to insurance companyUSD $15,589
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $62,383
Amount paid for insurance broker fees15589
Additional information about fees paid to insurance brokerOTHER COMMISSION
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 2
Insurance contract or identification number00
Number of Individuals Covered284
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $11,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10028661001
Policy instance 3
Insurance contract or identification number10028661001
Number of Individuals Covered356
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number138560000
Policy instance 4
Insurance contract or identification number138560000
Number of Individuals Covered433
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,558
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $250,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,558
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK604977
Policy instance 5
Insurance contract or identification numberSOK604977
Number of Individuals Covered203
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,345
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $78,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees1345
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK604977
Policy instance 5
Insurance contract or identification numberSOK604977
Number of Individuals Covered203
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $859
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $108,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees859
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number138560000
Policy instance 4
Insurance contract or identification number138560000
Number of Individuals Covered458
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,078
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $245,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,078
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10028661001
Policy instance 3
Insurance contract or identification number10028661001
Number of Individuals Covered399
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ALLONE HEALTH (National Association of Insurance Commissioners NAIC id number: 8741 )
Policy contract number00
Policy instance 2
Insurance contract or identification number00
Number of Individuals Covered191
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $7,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4953349
Policy instance 1
Insurance contract or identification number4953349
Number of Individuals Covered456
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $57,534
Total amount of fees paid to insurance companyUSD $16,313
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $57,534
Amount paid for insurance broker fees16313
Additional information about fees paid to insurance brokerOTHER COMMISSION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10028661001
Policy instance 5
Insurance contract or identification number10028661001
Number of Individuals Covered342
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $13,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK604977
Policy instance 4
Insurance contract or identification numberSOK604977
Number of Individuals Covered186
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $624
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $56,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees624
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number138560000
Policy instance 3
Insurance contract or identification number138560000
Number of Individuals Covered421
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $6,018
Total amount of fees paid to insurance companyUSD $80
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $244,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,018
Amount paid for insurance broker fees80
Additional information about fees paid to insurance brokerOTHER FEES
Insurance broker organization code?3
ALLONE HEALTH (National Association of Insurance Commissioners NAIC id number: 8741 )
Policy contract number00
Policy instance 2
Insurance contract or identification number00
Number of Individuals Covered191
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $7,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4953349
Policy instance 1
Insurance contract or identification number4953349
Number of Individuals Covered411
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $56,104
Total amount of fees paid to insurance companyUSD $17,010
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $56,104
Amount paid for insurance broker fees17010
Additional information about fees paid to insurance brokerOTHER COMMISSION
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4953349
Policy instance 1
Insurance contract or identification number4953349
Number of Individuals Covered425
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $53,987
Total amount of fees paid to insurance companyUSD $12,880
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $53,987
Amount paid for insurance broker fees12880
Additional information about fees paid to insurance brokerOTHER COMMISSION
Insurance broker organization code?3
ALLONE HEALTH (National Association of Insurance Commissioners NAIC id number: 8741 )
Policy contract number00
Policy instance 2
Insurance contract or identification number00
Number of Individuals Covered198
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $7,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10028661001
Policy instance 3
Insurance contract or identification number10028661001
Number of Individuals Covered321
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number138560000
Policy instance 4
Insurance contract or identification number138560000
Number of Individuals Covered409
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $6,037
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $244,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,037
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK604977
Policy instance 5
Insurance contract or identification numberSOK604977
Number of Individuals Covered198
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,030
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $84,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees1030
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK604977
Policy instance 6
Insurance contract or identification numberSOK604977
Number of Individuals Covered188
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,994
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $74,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees3994
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number13856-9901
Policy instance 5
Insurance contract or identification number13856-9901
Number of Individuals Covered446
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $9,231
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $267,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,231
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10028661001
Policy instance 4
Insurance contract or identification number10028661001
Number of Individuals Covered348
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ALLONE HEALTH (National Association of Insurance Commissioners NAIC id number: 8741 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered213
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $9,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number5488A
Policy instance 2
Insurance contract or identification number5488A
Number of Individuals Covered1
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4953349
Policy instance 1
Insurance contract or identification number4953349
Number of Individuals Covered450
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $55,833
Total amount of fees paid to insurance companyUSD $16,530
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $55,833
Amount paid for insurance broker fees16530
Additional information about fees paid to insurance brokerOTHER COMMISSION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.

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