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COVENANT EYES GROUP INSURANCE PLAN 401k Plan overview

Plan NameCOVENANT EYES GROUP INSURANCE PLAN
Plan identification number 501

COVENANT EYES GROUP INSURANCE 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

COVENANT EYES has sponsored the creation of one or more 401k plans.

Company Name:COVENANT EYES
Employer identification number (EIN):043734213
NAIC Classification:517000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COVENANT EYES GROUP INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01BRENDA HINDS2023-07-24
5012021-01-01BRENDA HINDS2022-08-22
5012020-01-01CHRIS TAPHOUSE2021-08-19
5012019-01-01BRENDA HINDS2020-07-20
5012018-01-01BRENDA HINDS2019-09-23
5012017-01-01
5012017-01-01BRENDA HINDS2021-02-02
5012016-01-01BRENDA HINDS2021-02-02

Plan Statistics for COVENANT EYES GROUP INSURANCE PLAN

401k plan membership statisitcs for COVENANT EYES GROUP INSURANCE PLAN

Measure Date Value
2022: COVENANT EYES GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01212
Total number of active participants reported on line 7a of the Form 55002022-01-01199
Number of retired or separated participants receiving benefits2022-01-011
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01200
Number of employers contributing to the scheme2022-01-010
2021: COVENANT EYES GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01207
Total number of active participants reported on line 7a of the Form 55002021-01-01212
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01212
Number of employers contributing to the scheme2021-01-010
2020: COVENANT EYES GROUP INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01195
Total number of active participants reported on line 7a of the Form 55002020-01-01206
Number of retired or separated participants receiving benefits2020-01-010
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: COVENANT EYES GROUP INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01181
Total number of active participants reported on line 7a of the Form 55002019-01-01195
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01195
Number of employers contributing to the scheme2019-01-010
2018: COVENANT EYES GROUP INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01167
Total number of active participants reported on line 7a of the Form 55002018-01-01181
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01181
Number of employers contributing to the scheme2018-01-010
2017: COVENANT EYES GROUP INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01147
Total number of active participants reported on line 7a of the Form 55002017-01-01167
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01167
Number of employers contributing to the scheme2017-01-010
2016: COVENANT EYES GROUP INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01100
Total number of active participants reported on line 7a of the Form 55002016-01-01147
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01147
Number of employers contributing to the scheme2016-01-010

Form 5500 Responses for COVENANT EYES GROUP INSURANCE PLAN

2022: COVENANT EYES GROUP INSURANCE 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: COVENANT EYES GROUP INSURANCE 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: COVENANT EYES GROUP INSURANCE 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: COVENANT EYES GROUP INSURANCE 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: COVENANT EYES GROUP INSURANCE 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: COVENANT EYES GROUP INSURANCE PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01First time form 5500 has been submittedYes
2017-01-01Submission has been amendedYes
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
2016: COVENANT EYES GROUP INSURANCE PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01First time form 5500 has been submittedYes
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BF92
Policy instance 6
Insurance contract or identification numberGLTD0BF92
Number of Individuals Covered201
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $16,201
Total amount of fees paid to insurance companyUSD $10,624
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $159,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,201
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerOTHER COMPENSATION
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract numberAGC0000159900
Policy instance 5
Insurance contract or identification numberAGC0000159900
Number of Individuals Covered103
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $10,188
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $32,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,188
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30095486
Policy instance 4
Insurance contract or identification number30095486
Number of Individuals Covered145
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,770
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,770
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number10123
Policy instance 3
Insurance contract or identification number10123
Number of Individuals Covered426
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $6,529
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,529
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00272173
Policy instance 2
Insurance contract or identification number00272173
Number of Individuals Covered237
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $48,230
Total amount of fees paid to insurance companyUSD $948
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,097
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number272173
Policy instance 1
Insurance contract or identification number272173
Number of Individuals Covered260
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $78,022
Total amount of fees paid to insurance companyUSD $1,224
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $57,462
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number272173
Policy instance 1
Insurance contract or identification number272173
Number of Individuals Covered282
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $37,062
Total amount of fees paid to insurance companyUSD $1,111
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,659
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number272173
Policy instance 2
Insurance contract or identification number272173
Number of Individuals Covered233
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $25,638
Total amount of fees paid to insurance companyUSD $917
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,333
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number10123
Policy instance 3
Insurance contract or identification number10123
Number of Individuals Covered405
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,533
Total amount of fees paid to insurance companyUSD $2,010
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,901
Amount paid for insurance broker fees2010
Additional information about fees paid to insurance brokerNEW BUSINESS BONUS
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30095486
Policy instance 4
Insurance contract or identification number30095486
Number of Individuals Covered143
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,083
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,542
Amount paid for insurance broker fees0
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number26253
Policy instance 5
Insurance contract or identification number26253
Number of Individuals Covered70
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $13,128
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $30,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,128
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BF92
Policy instance 6
Insurance contract or identification numberGLTD0BF92
Number of Individuals Covered212
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $16,159
Total amount of fees paid to insurance companyUSD $7,536
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $151,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,159
Amount paid for insurance broker fees7536
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BF92
Policy instance 6
Insurance contract or identification numberGLTD0BF92
Number of Individuals Covered206
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $14,449
Total amount of fees paid to insurance companyUSD $7,346
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $125,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,449
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerOTHER COMPENSATION
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number26253
Policy instance 5
Insurance contract or identification number26253
Number of Individuals Covered68
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10,510
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $17,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,510
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30095486
Policy instance 4
Insurance contract or identification number30095486
Number of Individuals Covered134
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,324
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,324
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number10123
Policy instance 3
Insurance contract or identification number10123
Number of Individuals Covered355
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,753
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,753
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number272173
Policy instance 2
Insurance contract or identification number272173
Number of Individuals Covered223
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $31,875
Total amount of fees paid to insurance companyUSD $1,068
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,875
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number272173
Policy instance 1
Insurance contract or identification number272173
Number of Individuals Covered249
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $55,458
Total amount of fees paid to insurance companyUSD $1,227
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $55,458
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number272173
Policy instance 1
Insurance contract or identification number272173
Number of Individuals Covered323
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $25,605
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,226
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number272173
Policy instance 2
Insurance contract or identification number272173
Number of Individuals Covered124
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $8,931
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,171
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4831749
Policy instance 3
Insurance contract or identification numberE4831749
Number of Individuals Covered32
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,392
Total amount of fees paid to insurance companyUSD $331
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $31,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,430
Amount paid for insurance broker fees213
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-046595
Policy instance 4
Insurance contract or identification number010-046595
Number of Individuals Covered259
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,604
Total amount of fees paid to insurance companyUSD $4,936
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $132,696
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 fees4936
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BF92
Policy instance 5
Insurance contract or identification numberGLTD0BF92
Number of Individuals Covered195
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $12,884
Total amount of fees paid to insurance companyUSD $4,775
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $104,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,884
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerOTHER COMPENSATION
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05988333
Policy instance 2
Insurance contract or identification numberKM05988333
Number of Individuals Covered286
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $14,279
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $184,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,279
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLEONARD WRIGHT
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number7022031
Policy instance 1
Insurance contract or identification number7022031
Number of Individuals Covered370
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $39,166
Total amount of fees paid to insurance companyUSD $1,803
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,078
Amount paid for insurance broker fees1803
Additional information about fees paid to insurance brokerFEES AND OTHER COMISSIONS
Insurance broker organization code?3
Insurance broker nameGROTENHUIS
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract numberCID 272173
Policy instance 1
Insurance contract or identification numberCID 272173
Number of Individuals Covered346
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $51,097
Total amount of fees paid to insurance companyUSD $735
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,281
Amount paid for insurance broker fees735
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5988333
Policy instance 2
Insurance contract or identification number5988333
Number of Individuals Covered317
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $1,244
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $177,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,244
Amount paid for insurance broker fees0
Insurance broker organization code?3

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