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DIVERSE CONCEPTS, LLC 401k Plan overview

Plan NameDIVERSE CONCEPTS, LLC
Plan identification number 501

DIVERSE CONCEPTS, LLC Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover

401k Sponsoring company profile

DIVERSE CONCEPTS, LLC has sponsored the creation of one or more 401k plans.

Company Name:DIVERSE CONCEPTS, LLC
Employer identification number (EIN):043803020
NAIC Classification:541600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DIVERSE CONCEPTS, LLC

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01MARK SMITH2023-10-09 MARK SMITH2023-10-09
5012021-01-01MARK SMITH2022-10-12 MARK SMITH2022-10-12
5012020-01-01MARK SMITH2021-10-04 MARK SMITH2021-10-04
5012019-01-01MARK SMITH2020-10-12 MARK SMITH2020-10-12
5012018-01-01MARK SMITH2019-10-03 MARK SMITH2019-10-03
5012017-01-01
5012016-01-01

Plan Statistics for DIVERSE CONCEPTS, LLC

401k plan membership statisitcs for DIVERSE CONCEPTS, LLC

Measure Date Value
2022: DIVERSE CONCEPTS, LLC 2022 401k membership
Total participants, beginning-of-year2022-01-01328
Total number of active participants reported on line 7a of the Form 55002022-01-01329
Total of all active and inactive participants2022-01-01329
2021: DIVERSE CONCEPTS, LLC 2021 401k membership
Total participants, beginning-of-year2021-01-01290
Total number of active participants reported on line 7a of the Form 55002021-01-01328
Total of all active and inactive participants2021-01-01328
2020: DIVERSE CONCEPTS, LLC 2020 401k membership
Total participants, beginning-of-year2020-01-01290
Total number of active participants reported on line 7a of the Form 55002020-01-01290
Total of all active and inactive participants2020-01-01290
2019: DIVERSE CONCEPTS, LLC 2019 401k membership
Total participants, beginning-of-year2019-01-01341
Total number of active participants reported on line 7a of the Form 55002019-01-01290
Total of all active and inactive participants2019-01-01290
2018: DIVERSE CONCEPTS, LLC 2018 401k membership
Total participants, beginning-of-year2018-01-01254
Total number of active participants reported on line 7a of the Form 55002018-01-01341
Total of all active and inactive participants2018-01-01341
2017: DIVERSE CONCEPTS, LLC 2017 401k membership
Total participants, beginning-of-year2017-01-01220
Total number of active participants reported on line 7a of the Form 55002017-01-01254
Total of all active and inactive participants2017-01-01254
2016: DIVERSE CONCEPTS, LLC 2016 401k membership
Total participants, beginning-of-year2016-01-01210
Total number of active participants reported on line 7a of the Form 55002016-01-01220
Total of all active and inactive participants2016-01-01220

Form 5500 Responses for DIVERSE CONCEPTS, LLC

2022: DIVERSE CONCEPTS, LLC 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: DIVERSE CONCEPTS, LLC 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: DIVERSE CONCEPTS, LLC 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: DIVERSE CONCEPTS, LLC 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: DIVERSE CONCEPTS, LLC 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: DIVERSE CONCEPTS, LLC 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
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: DIVERSE CONCEPTS, LLC 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

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020343
Policy instance 4
Insurance contract or identification number50020343
Number of Individuals Covered212
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,672
Total amount of fees paid to insurance companyUSD $1,045
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $42,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,226
Insurance broker organization code?3
Amount paid for insurance broker fees1045
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020343
Policy instance 3
Insurance contract or identification number50020343
Number of Individuals Covered212
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $6,800
Total amount of fees paid to insurance companyUSD $820
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,098
Insurance broker organization code?3
Amount paid for insurance broker fees820
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020343
Policy instance 2
Insurance contract or identification number50020343
Number of Individuals Covered212
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,690
Total amount of fees paid to insurance companyUSD $324
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $13,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,621
Insurance broker organization code?3
Amount paid for insurance broker fees324
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number99899
Policy instance 1
Insurance contract or identification number99899
Number of Individuals Covered329
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $12,134
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,134
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number99899
Policy instance 1
Insurance contract or identification number99899
Number of Individuals Covered328
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $75,478
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75,478
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031236
Policy instance 3
Insurance contract or identification number10031236
Number of Individuals Covered205
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $3,812
Total amount of fees paid to insurance companyUSD $329
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,812
Insurance broker organization code?3
Amount paid for insurance broker fees329
Additional information about fees paid to insurance brokerBROKER BONUS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031235
Policy instance 4
Insurance contract or identification number10031235
Number of Individuals Covered205
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $9,138
Total amount of fees paid to insurance companyUSD $789
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $60,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,138
Insurance broker organization code?3
Amount paid for insurance broker fees789
Additional information about fees paid to insurance brokerBROKER BONUS
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020343
Policy instance 2
Insurance contract or identification number50020343
Number of Individuals Covered203
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,396
Total amount of fees paid to insurance companyUSD $223
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $11,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,670
Insurance broker organization code?3
Amount paid for insurance broker fees223
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020343
Policy instance 2
Insurance contract or identification number50020343
Number of Individuals Covered181
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,494
Total amount of fees paid to insurance companyUSD $481
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $24,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,608
Insurance broker organization code?3
Amount paid for insurance broker fees481
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031236
Policy instance 3
Insurance contract or identification number10031236
Number of Individuals Covered178
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,562
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,562
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031235
Policy instance 4
Insurance contract or identification number10031235
Number of Individuals Covered178
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $8,539
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $56,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,539
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number99899
Policy instance 1
Insurance contract or identification number99899
Number of Individuals Covered290
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $80,907
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $80,907
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031235
Policy instance 5
Insurance contract or identification number10031235
Number of Individuals Covered180
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $8,354
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $55,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,354
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031236
Policy instance 4
Insurance contract or identification number10031236
Number of Individuals Covered180
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,504
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,504
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97778481001
Policy instance 2
Insurance contract or identification number97778481001
Number of Individuals Covered249
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,040
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,040
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number99899
Policy instance 1
Insurance contract or identification number99899
Number of Individuals Covered290
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $76,431
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
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 $76,431
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020343
Policy instance 3
Insurance contract or identification number50020343
Number of Individuals Covered183
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,610
Total amount of fees paid to insurance companyUSD $476
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $23,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,570
Insurance broker organization code?3
Amount paid for insurance broker fees476
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031235
Policy instance 5
Insurance contract or identification number10031235
Number of Individuals Covered171
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $7,786
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $51,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,786
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031236
Policy instance 4
Insurance contract or identification number10031236
Number of Individuals Covered170
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,304
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,304
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020343
Policy instance 3
Insurance contract or identification number50020343
Number of Individuals Covered172
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $4,134
Total amount of fees paid to insurance companyUSD $464
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $23,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,478
Insurance broker organization code?3
Amount paid for insurance broker fees464
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97778481001
Policy instance 2
Insurance contract or identification number97778481001
Number of Individuals Covered227
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,060
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,060
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number99899
Policy instance 1
Insurance contract or identification number99899
Number of Individuals Covered341
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $72,749
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
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 $72,749
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97778481001
Policy instance 2
Insurance contract or identification number97778481001
Number of Individuals Covered177
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,465
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,465
Insurance broker organization code?3
Insurance broker nameTIS INSURANCE SERVICES,INC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020343
Policy instance 3
Insurance contract or identification number50020343
Number of Individuals Covered154
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,798
Total amount of fees paid to insurance companyUSD $388
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $19,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,914
Insurance broker organization code?3
Amount paid for insurance broker fees388
Additional information about fees paid to insurance brokerMANAGEMENT FEES
Insurance broker nameGROUP INSURANCE SERVICES,INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031236
Policy instance 4
Insurance contract or identification number10031236
Number of Individuals Covered146
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,632
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,632
Insurance broker organization code?3
Insurance broker nameTIS INSURANCE SERVICES, INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10031235
Policy instance 5
Insurance contract or identification number10031235
Number of Individuals Covered147
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $6,418
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $42,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,418
Insurance broker organization code?3
Insurance broker nameTIS INSURANCE SERVICES, INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910084
Policy instance 6
Insurance contract or identification number910084
Number of Individuals Covered254
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 $32,984
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $970,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees29984
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameTIS INSURANCE SERVICES, INC
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number99899
Policy instance 1
Insurance contract or identification number99899
Number of Individuals Covered214
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,426
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $54,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,426
Insurance broker organization code?3
Insurance broker nameBENJAMIN KELLY

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