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AMESBURYTRUTH MEDICAL PLAN 401k Plan overview

Plan NameAMESBURYTRUTH MEDICAL PLAN
Plan identification number 501

AMESBURYTRUTH MEDICAL 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

AMESBURY INDUSTRIES, INC. has sponsored the creation of one or more 401k plans.

Company Name:AMESBURY INDUSTRIES, INC.
Employer identification number (EIN):112557875
NAIC Classification:327300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMESBURYTRUTH MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01DENELL HELLER2023-06-27
5012021-01-01JEANNINE EDGREN2022-07-19
5012020-01-01SCOTT ROGGENBAUER2021-07-01
5012019-01-01DAMON ANDERSON2020-07-22
5012019-01-01SCOTT ROGGENBAUER2021-07-01
5012018-01-01DAMON ANDERSON2019-08-12
5012018-01-01SCOTT ROGGENBAUER2021-07-01
5012017-01-01
5012017-01-01SCOTT ROGGENBAUER2021-07-01
5012016-01-01JONATHAN W LUECK
5012016-01-01SCOTT ROGGENBAUER2021-07-01

Plan Statistics for AMESBURYTRUTH MEDICAL PLAN

401k plan membership statisitcs for AMESBURYTRUTH MEDICAL PLAN

Measure Date Value
2022: AMESBURYTRUTH MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-011,371
Total number of active participants reported on line 7a of the Form 55002022-01-011,221
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 participants2022-01-011,233
2021: AMESBURYTRUTH MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-011,390
Total number of active participants reported on line 7a of the Form 55002021-01-011,227
Number of retired or separated participants receiving benefits2021-01-0114
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-011,241
Number of employers contributing to the scheme2021-01-010
2020: AMESBURYTRUTH MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01935
Total number of active participants reported on line 7a of the Form 55002020-01-01846
Number of retired or separated participants receiving benefits2020-01-0125
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01871
Number of employers contributing to the scheme2020-01-010
2019: AMESBURYTRUTH MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-011,020
Total number of active participants reported on line 7a of the Form 55002019-01-011,294
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 participants2019-01-011,294
Number of employers contributing to the scheme2019-01-010
2018: AMESBURYTRUTH MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-011,164
Total number of active participants reported on line 7a of the Form 55002018-01-011,002
Number of retired or separated participants receiving benefits2018-01-0118
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-011,020
Number of employers contributing to the scheme2018-01-010
2017: AMESBURYTRUTH MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-011,320
Total number of active participants reported on line 7a of the Form 55002017-01-011,061
Number of retired or separated participants receiving benefits2017-01-0140
Number of other retired or separated participants entitled to future benefits2017-01-0163
Total of all active and inactive participants2017-01-011,164
Number of employers contributing to the scheme2017-01-010
2016: AMESBURYTRUTH MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-011,711
Total number of active participants reported on line 7a of the Form 55002016-01-011,832
Number of retired or separated participants receiving benefits2016-01-0140
Number of other retired or separated participants entitled to future benefits2016-01-0163
Total of all active and inactive participants2016-01-011,935
Number of employers contributing to the scheme2016-01-010

Form 5500 Responses for AMESBURYTRUTH MEDICAL PLAN

2022: AMESBURYTRUTH MEDICAL PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
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: AMESBURYTRUTH MEDICAL PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
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: AMESBURYTRUTH MEDICAL 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: AMESBURYTRUTH MEDICAL PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
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: AMESBURYTRUTH MEDICAL PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedYes
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: AMESBURYTRUTH MEDICAL PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
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: AMESBURYTRUTH MEDICAL PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01First time form 5500 has been submittedYes
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
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

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12272392
Policy instance 2
Insurance contract or identification number12272392
Number of Individuals Covered291
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
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
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 CarrierUSD $159,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number000
Policy instance 6
Insurance contract or identification number000
Number of Individuals Covered831
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 $39,645
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,592,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )
Policy contract number2171
Policy instance 1
Insurance contract or identification number2171
Number of Individuals Covered1624
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $25,311
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $657,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,311
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0000169298
Policy instance 3
Insurance contract or identification number0000169298
Number of Individuals Covered11
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,920
Total amount of fees paid to insurance companyUSD $507
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY
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 CarrierUSD $18,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,814
Amount paid for insurance broker fees507
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
COUNSELING GLOBAL DOMESTIC (National Association of Insurance Commissioners NAIC id number: 54161 )
Policy contract number459347
Policy instance 4
Insurance contract or identification number459347
Number of Individuals Covered1356
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
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEAP
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 CarrierUSD $52,515
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number803878G
Policy instance 5
Insurance contract or identification number803878G
Number of Individuals Covered1221
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $27,823
Total amount of fees paid to insurance companyUSD $0
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 & 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 CarrierUSD $927,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,823
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number430947
Policy instance 7
Insurance contract or identification number430947
Number of Individuals Covered107
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $4,599
Total amount of fees paid to insurance companyUSD $366
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHOSPITAL INDEMNITY
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 CarrierUSD $12,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $642
Amount paid for insurance broker fees169
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number430946
Policy instance 6
Insurance contract or identification number430946
Number of Individuals Covered100
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $3,354
Total amount of fees paid to insurance companyUSD $823
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSPECIFIED DISEASE
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 CarrierUSD $22,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $786
Amount paid for insurance broker fees210
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number803878G
Policy instance 3
Insurance contract or identification number803878G
Number of Individuals Covered1865
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $26,457
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 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 providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $882,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,157
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12272392
Policy instance 2
Insurance contract or identification number12272392
Number of Individuals Covered865
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
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 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
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract number614407
Policy instance 8
Insurance contract or identification number614407
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,400
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $4,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $531
Insurance broker organization code?3
DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )
Policy contract number2171
Policy instance 1
Insurance contract or identification number2171
Number of Individuals Covered1721
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $25,065
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $651,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,534
Insurance broker organization code?3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number430945
Policy instance 5
Insurance contract or identification number430945
Number of Individuals Covered114
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,015
Total amount of fees paid to insurance companyUSD $520
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT
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 CarrierUSD $17,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $897
Amount paid for insurance broker fees240
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
VALUEOPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )
Policy contract number
Policy instance 4
Number of Individuals Covered1224
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
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEAP
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 CarrierUSD $21,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG00614407
Policy instance 4
Insurance contract or identification numberG00614407
Number of Individuals Covered52
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,831
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,282
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )
Policy contract number2171
Policy instance 2
Insurance contract or identification number2171
Number of Individuals Covered1691
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $25,237
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $692,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,237
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract numberG0933
Policy instance 5
Insurance contract or identification numberG0933
Number of Individuals Covered78
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $7,360
Total amount of fees paid to insurance companyUSD $30
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $67,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,989
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12272392
Policy instance 3
Insurance contract or identification number12272392
Number of Individuals Covered837
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 $179,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number803878G
Policy instance 1
Insurance contract or identification number803878G
Number of Individuals Covered1225
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $27,299
Total amount of fees paid to insurance companyUSD $0
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 $940,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,299
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number473103SCHLGLIF
Policy instance 8
Insurance contract or identification number473103SCHLGLIF
Number of Individuals Covered533
Insurance policy start date2019-01-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $14,943
Total amount of fees paid to insurance companyUSD $0
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 $489,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,943
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract numberG0933
Policy instance 7
Insurance contract or identification numberG0933
Number of Individuals Covered93
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $13,108
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $71,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,180
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG00614407
Policy instance 4
Insurance contract or identification numberG00614407
Number of Individuals Covered58
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,244
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,571
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 number12272392
Policy instance 3
Insurance contract or identification number12272392
Number of Individuals Covered871
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
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $151,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )
Policy contract number2171
Policy instance 2
Insurance contract or identification number2171
Number of Individuals Covered1892
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $29,080
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $755,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,080
Amount paid for insurance broker fees0
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number803878G
Policy instance 1
Insurance contract or identification number803878G
Number of Individuals Covered1294
Insurance policy start date2019-09-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $7,230
Total amount of fees paid to insurance companyUSD $0
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 $179,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,230
Amount paid for insurance broker fees0
Insurance broker organization code?3
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number7467
Policy instance 5
Insurance contract or identification number7467
Number of Individuals Covered2
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $14,936
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $360,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,908
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )
Policy contract number2171
Policy instance 2
Insurance contract or identification number2171
Number of Individuals Covered2199
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $32,374
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $840,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,374
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12272392
Policy instance 3
Insurance contract or identification number12272392
Number of Individuals Covered866
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG00614407
Policy instance 4
Insurance contract or identification numberG00614407
Number of Individuals Covered75
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,078
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $10,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,155
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number473103TRHRDLIF
Policy instance 6
Insurance contract or identification number473103TRHRDLIF
Number of Individuals Covered1883
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $22,859
Total amount of fees paid to insurance companyUSD $0
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 $762,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,859
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number7467
Policy instance 5
Insurance contract or identification number7467
Number of Individuals Covered119
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
Welfare Benefit Premiums Paid to CarrierUSD $1,704,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract numberG0933
Policy instance 1
Insurance contract or identification numberG0933
Number of Individuals Covered37
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $12,828
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER, VOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $20,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,974
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3837762
Policy instance 10
Insurance contract or identification numberE3837762
Number of Individuals Covered19
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $186
Total amount of fees paid to insurance companyUSD $36
Other welfare benefits providedVOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $1,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $67
Amount paid for insurance broker fees8
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract numberV9094
Policy instance 1
Insurance contract or identification numberV9094
Number of Individuals Covered256
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $66,333
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $111,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $46,518
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 )
Policy contract number2171
Policy instance 2
Insurance contract or identification number2171
Number of Individuals Covered2144
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $32,884
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $854,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,884
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 number12272392
Policy instance 3
Insurance contract or identification number12272392
Number of Individuals Covered852
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
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 $159,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG00614407
Policy instance 4
Insurance contract or identification numberG00614407
Number of Individuals Covered59
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $2,062
Total amount of fees paid to insurance companyUSD $1,389
Other welfare benefits providedDISABILITY
Welfare Benefit Premiums Paid to CarrierUSD $6,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,443
Amount paid for insurance broker fees1389
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4067500
Policy instance 6
Insurance contract or identification numberE4067500
Number of Individuals Covered122
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $2,074
Total amount of fees paid to insurance companyUSD $463
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $9,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $680
Amount paid for insurance broker fees87
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3837846
Policy instance 7
Insurance contract or identification numberE3837846
Number of Individuals Covered23
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $699
Total amount of fees paid to insurance companyUSD $162
Other welfare benefits providedVOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $3,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $233
Amount paid for insurance broker fees30
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3829652
Policy instance 8
Insurance contract or identification numberE3829652
Number of Individuals Covered30
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $324
Total amount of fees paid to insurance companyUSD $74
Other welfare benefits providedVOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $2,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $105
Amount paid for insurance broker fees13
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3829645
Policy instance 9
Insurance contract or identification numberE3829645
Number of Individuals Covered16
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $220
Total amount of fees paid to insurance companyUSD $43
Other welfare benefits providedVOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $1,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $76
Amount paid for insurance broker fees10
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3837838
Policy instance 11
Insurance contract or identification numberE3837838
Number of Individuals Covered18
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $466
Total amount of fees paid to insurance companyUSD $102
Other welfare benefits providedVOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $2,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $140
Amount paid for insurance broker fees18
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number501320/7467
Policy instance 5
Insurance contract or identification number501320/7467
Number of Individuals Covered193
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $73,033
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,024,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $72,580
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number473103TRHRDLIF
Policy instance 13
Insurance contract or identification number473103TRHRDLIF
Number of Individuals Covered1832
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $30,906
Total amount of fees paid to insurance companyUSD $92
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 $856,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $19,132
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION

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