401k Plan data: HEALTH & WELFARE BENEFITS plan

HEALTH & WELFARE BENEFITS 401k Plan overview

Plan Name	HEALTH & WELFARE BENEFITS
Plan identification number	501

HEALTH & WELFARE BENEFITS Benefits

401k Plan Type

Welfare 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)
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

NATIONAL URBAN LEAGUE has sponsored the creation of one or more 401k plans.

Company Name: NATIONAL URBAN LEAGUE

Employer identification number (EIN): 131840489

NAIC Classification: 813000
NAIC Description: Religious, Grantmaking, Civic, Professional, and Similar Organizations

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HEALTH & WELFARE BENEFITS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 WANDA JACKSON 2023-10-05
501 2021-01-01 WANDA JACKSON 2023-10-05
501 2020-01-01 WANDA JACKSON 2021-10-13
501 2019-01-01 WANDA JACKSON 2020-07-27
501 2018-01-01 WANDA JACKSON 2019-10-15
501 2017-01-01
501 2016-01-01
501 2015-01-01
501 2014-01-01
501 2013-01-01
501 2012-01-01 WANDA JACKSON
501 2011-01-01 WANDA JACKSON
501 2010-01-01 WANDA JACKSON
501 2009-01-01 WANDA JACKSON
501 2009-01-01 WANDA JACKSON
501 2009-01-01 WANDA JACKSON

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	WANDA JACKSON	2023-10-05
501	2021-01-01	WANDA JACKSON	2023-10-05
501	2020-01-01	WANDA JACKSON	2021-10-13
501	2019-01-01	WANDA JACKSON	2020-07-27
501	2018-01-01	WANDA JACKSON	2019-10-15
501	2017-01-01
501	2016-01-01
501	2015-01-01
501	2014-01-01
501	2013-01-01
501	2012-01-01	WANDA JACKSON
501	2011-01-01	WANDA JACKSON
501	2010-01-01	WANDA JACKSON
501	2009-01-01	WANDA JACKSON
501	2009-01-01	WANDA JACKSON
501	2009-01-01	WANDA JACKSON

Plan Statistics for HEALTH & WELFARE BENEFITS

401k plan membership statisitcs for HEALTH & WELFARE BENEFITS

Measure Date Value
2022: HEALTH & WELFARE BENEFITS 2022 401k membership
Total participants, beginning-of-year 2022-01-01 82
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 96
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 96
Number of employers contributing to the scheme 2022-01-01 0
2021: HEALTH & WELFARE BENEFITS 2021 401k membership
Total participants, beginning-of-year 2021-01-01 81
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 82
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 82
Number of employers contributing to the scheme 2021-01-01 0
2020: HEALTH & WELFARE BENEFITS 2020 401k membership
Total participants, beginning-of-year 2020-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 81
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 81
Number of employers contributing to the scheme 2020-01-01 0
2019: HEALTH & WELFARE BENEFITS 2019 401k membership
Total participants, beginning-of-year 2019-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 106
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 106
Number of employers contributing to the scheme 2019-01-01 0
2018: HEALTH & WELFARE BENEFITS 2018 401k membership
Total participants, beginning-of-year 2018-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 100
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 100
Number of employers contributing to the scheme 2018-01-01 0
2017: HEALTH & WELFARE BENEFITS 2017 401k membership
Total participants, beginning-of-year 2017-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 100
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 100
2016: HEALTH & WELFARE BENEFITS 2016 401k membership
Total participants, beginning-of-year 2016-01-01 87
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 91
Total of all active and inactive participants 2016-01-01 91
Total participants 2016-01-01 91
2015: HEALTH & WELFARE BENEFITS 2015 401k membership
Total participants, beginning-of-year 2015-01-01 103
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 84
Number of retired or separated participants receiving benefits 2015-01-01 2
Total of all active and inactive participants 2015-01-01 86
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 1
Total participants 2015-01-01 87
2014: HEALTH & WELFARE BENEFITS 2014 401k membership
Total participants, beginning-of-year 2014-01-01 92
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 100
Number of retired or separated participants receiving benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 102
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 1
Total participants 2014-01-01 103
2013: HEALTH & WELFARE BENEFITS 2013 401k membership
Total participants, beginning-of-year 2013-01-01 88
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 92
Total of all active and inactive participants 2013-01-01 92
Total participants 2013-01-01 92
2012: HEALTH & WELFARE BENEFITS 2012 401k membership
Total participants, beginning-of-year 2012-01-01 88
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 88
Total of all active and inactive participants 2012-01-01 88
Total participants 2012-01-01 88
2011: HEALTH & WELFARE BENEFITS 2011 401k membership
Total participants, beginning-of-year 2011-01-01 94
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 88
Total of all active and inactive participants 2011-01-01 88
Total participants 2011-01-01 88
2010: HEALTH & WELFARE BENEFITS 2010 401k membership
Total participants, beginning-of-year 2010-01-01 86
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 94
Total of all active and inactive participants 2010-01-01 94
Total participants 2010-01-01 94
2009: HEALTH & WELFARE BENEFITS 2009 401k membership
Total participants, beginning-of-year 2009-01-01 92
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 86
Total of all active and inactive participants 2009-01-01 86
Total participants 2009-01-01 86

Measure	Date	Value
2022: HEALTH & WELFARE BENEFITS 2022 401k membership
Total participants, beginning-of-year	2022-01-01	82
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	96
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	96
Number of employers contributing to the scheme	2022-01-01	0
2021: HEALTH & WELFARE BENEFITS 2021 401k membership
Total participants, beginning-of-year	2021-01-01	81
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	82
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	82
Number of employers contributing to the scheme	2021-01-01	0
2020: HEALTH & WELFARE BENEFITS 2020 401k membership
Total participants, beginning-of-year	2020-01-01	106
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	81
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	81
Number of employers contributing to the scheme	2020-01-01	0
2019: HEALTH & WELFARE BENEFITS 2019 401k membership
Total participants, beginning-of-year	2019-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	106
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	106
Number of employers contributing to the scheme	2019-01-01	0
2018: HEALTH & WELFARE BENEFITS 2018 401k membership
Total participants, beginning-of-year	2018-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	100
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	100
Number of employers contributing to the scheme	2018-01-01	0
2017: HEALTH & WELFARE BENEFITS 2017 401k membership
Total participants, beginning-of-year	2017-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	100
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	100
2016: HEALTH & WELFARE BENEFITS 2016 401k membership
Total participants, beginning-of-year	2016-01-01	87
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	91
Total of all active and inactive participants	2016-01-01	91
Total participants	2016-01-01	91
2015: HEALTH & WELFARE BENEFITS 2015 401k membership
Total participants, beginning-of-year	2015-01-01	103
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	84
Number of retired or separated participants receiving benefits	2015-01-01	2
Total of all active and inactive participants	2015-01-01	86
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	1
Total participants	2015-01-01	87
2014: HEALTH & WELFARE BENEFITS 2014 401k membership
Total participants, beginning-of-year	2014-01-01	92
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	100
Number of retired or separated participants receiving benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	102
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	1
Total participants	2014-01-01	103
2013: HEALTH & WELFARE BENEFITS 2013 401k membership
Total participants, beginning-of-year	2013-01-01	88
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	92
Total of all active and inactive participants	2013-01-01	92
Total participants	2013-01-01	92
2012: HEALTH & WELFARE BENEFITS 2012 401k membership
Total participants, beginning-of-year	2012-01-01	88
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	88
Total of all active and inactive participants	2012-01-01	88
Total participants	2012-01-01	88
2011: HEALTH & WELFARE BENEFITS 2011 401k membership
Total participants, beginning-of-year	2011-01-01	94
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	88
Total of all active and inactive participants	2011-01-01	88
Total participants	2011-01-01	88
2010: HEALTH & WELFARE BENEFITS 2010 401k membership
Total participants, beginning-of-year	2010-01-01	86
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	94
Total of all active and inactive participants	2010-01-01	94
Total participants	2010-01-01	94
2009: HEALTH & WELFARE BENEFITS 2009 401k membership
Total participants, beginning-of-year	2009-01-01	92
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	86
Total of all active and inactive participants	2009-01-01	86
Total participants	2009-01-01	86

Form 5500 Responses for HEALTH & WELFARE BENEFITS

2022: HEALTH & WELFARE BENEFITS 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: HEALTH & WELFARE BENEFITS 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: HEALTH & WELFARE BENEFITS 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: HEALTH & WELFARE BENEFITS 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: HEALTH & WELFARE BENEFITS 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: HEALTH & WELFARE BENEFITS 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: HEALTH & WELFARE BENEFITS 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: HEALTH & WELFARE BENEFITS 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: HEALTH & WELFARE BENEFITS 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: HEALTH & WELFARE BENEFITS 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: HEALTH & WELFARE BENEFITS 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: HEALTH & WELFARE BENEFITS 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: HEALTH & WELFARE BENEFITS 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	Yes
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: HEALTH & WELFARE BENEFITS 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	96
Insurance policy start date	2021-04-01
Insurance policy end date	2022-03-31
Total amount of commissions paid to insurance broker	USD $26,194
Total amount of fees paid to insurance company	USD $3,581
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $208,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,194
Amount paid for insurance broker fees	3581
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	82
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $23,205
Total amount of fees paid to insurance company	USD $3,119
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $178,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,205
Amount paid for insurance broker fees	3119
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334319

Policy instance

Insurance contract or identification number	3334319
Number of Individuals Covered	74
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,043
Total amount of fees paid to insurance company	USD $90,488
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,526,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,043
Amount paid for insurance broker fees	58822
Additional information about fees paid to insurance broker	BENEFIT ADVISOR PAYMENTS
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	81
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $20,916
Total amount of fees paid to insurance company	USD $2,268
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $183,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,916
Amount paid for insurance broker fees	2268
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	73
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $703
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $703
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1102177000

Policy instance

Insurance contract or identification number	1102177000
Number of Individuals Covered	81
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

99073291

Policy instance

Insurance contract or identification number	99073291
Number of Individuals Covered	81
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	106
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $26,660
Total amount of fees paid to insurance company	USD $2,715
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $217,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,660
Amount paid for insurance broker fees	2715
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334319

Policy instance

Insurance contract or identification number	3334319
Number of Individuals Covered	79
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,700
Total amount of fees paid to insurance company	USD $109,538
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,816,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,700
Amount paid for insurance broker fees	71480
Additional information about fees paid to insurance broker	BENEFIT ADVISOR PAYMENTS SERVICE/GENERAL AGENT PAYMENTS
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	78
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $773
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $773
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

1102177000

Policy instance

Insurance contract or identification number	1102177000
Number of Individuals Covered	1
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	97
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $821
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $821
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334319

Policy instance

Insurance contract or identification number	3334319
Number of Individuals Covered	98
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $84,210
Total amount of fees paid to insurance company	USD $5,231
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,042,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $84,210
Amount paid for insurance broker fees	1858
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	114
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $26,870
Total amount of fees paid to insurance company	USD $1,858
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $211,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,870
Amount paid for insurance broker fees	1858
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468000

Policy instance

Insurance contract or identification number	1009468000
Number of Individuals Covered	1
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

000099073291

Policy instance

Insurance contract or identification number	000099073291
Number of Individuals Covered	100
Insurance policy start date	2017-05-01
Insurance policy end date	2018-04-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334319

Policy instance

Insurance contract or identification number	3334319
Number of Individuals Covered	98
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $77,203
Total amount of fees paid to insurance company	USD $3,759
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,866,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $77,203
Amount paid for insurance broker fees	3759
Additional information about fees paid to insurance broker	SERVICE/GENERAL AGENTFEES INCENTIVE COMPENSATION
Insurance broker organization code?	3
Insurance broker name	UNKNOWN

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	100
Insurance policy start date	2016-04-01
Insurance policy end date	2017-03-31
Total amount of commissions paid to insurance broker	USD $23,300
Total amount of fees paid to insurance company	USD $2,007
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $178,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,300
Amount paid for insurance broker fees	2007
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099073291

Policy instance

Insurance contract or identification number	000099073291
Number of Individuals Covered	151
Insurance policy start date	2016-05-01
Insurance policy end date	2017-04-30
Total amount of commissions paid to insurance broker	USD $225
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $15,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $225
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	J. P. WEST, INC.

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468000

Policy instance

Insurance contract or identification number	1009468000
Number of Individuals Covered	2
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $403
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $403
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	JOSE RIVERA

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	99
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $775
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $775
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

454993

Policy instance

Insurance contract or identification number	454993
Number of Individuals Covered	98
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $461
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $461
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES CORP

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099073291

Policy instance

Insurance contract or identification number	000099073291
Number of Individuals Covered	151
Insurance policy start date	2015-05-01
Insurance policy end date	2016-05-01
Total amount of commissions paid to insurance broker	USD $225
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $225
Insurance broker organization code?	3
Insurance broker name	J.P. WEST, INC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468-000

Policy instance

Insurance contract or identification number	1009468-000
Number of Individuals Covered	3
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $329
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $329
Insurance broker organization code?	3
Insurance broker name	PROGRESSIVE PLAN ADMIN

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334319

Policy instance

Insurance contract or identification number	3334319
Number of Individuals Covered	87
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $65,712
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,642,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $65,712
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	86
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $741
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $741
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

887369

Policy instance

Insurance contract or identification number	887369
Number of Individuals Covered	84
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,961
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,961
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468-000/800

Policy instance

Insurance contract or identification number	1009468-000/800
Number of Individuals Covered	1
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10
Insurance broker organization code?	3
Insurance broker name	PROGRESSIVE PLAN ADMIN

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	138
Insurance policy start date	2015-01-01
Insurance policy end date	2016-01-01
Total amount of commissions paid to insurance broker	USD $26,308
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $184,177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,308
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES CORP

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	140
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $27,538
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $198,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $27,538
Insurance broker name	USI INSURANCE SERVICES LLC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468-000/800

Policy instance

Insurance contract or identification number	1009468-000/800
Number of Individuals Covered	1
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $10
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10
Insurance broker organization code?	3
Insurance broker name	PROGRESSIVE PLAN ADMIN

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

887369

Policy instance

Insurance contract or identification number	887369
Number of Individuals Covered	95
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,840
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,840
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	94
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $741
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $741
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099073291

Policy instance

Insurance contract or identification number	000099073291
Number of Individuals Covered	151
Insurance policy start date	2014-05-01
Insurance policy end date	2015-05-01
Total amount of commissions paid to insurance broker	USD $225
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $225
Insurance broker organization code?	3
Insurance broker name	J.P. WEST, INC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468-000

Policy instance

Insurance contract or identification number	1009468-000
Number of Individuals Covered	3
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $320
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $320
Insurance broker organization code?	3
Insurance broker name	PROGRESSIVE PLAN ADMIN

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

454993

Policy instance

Insurance contract or identification number	454993
Number of Individuals Covered	105
Insurance policy start date	2014-01-01
Insurance policy end date	2015-01-01
Total amount of commissions paid to insurance broker	USD $715
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $715
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334319

Policy instance

Insurance contract or identification number	3334319
Number of Individuals Covered	96
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $61,014
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,525,340
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $61,014
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	94
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $709
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $709
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334319

Policy instance

Insurance contract or identification number	3334319
Number of Individuals Covered	93
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $57,394
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,434,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57,394
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	148
Insurance policy start date	2013-02-01
Insurance policy end date	2014-02-01
Total amount of commissions paid to insurance broker	USD $26,068
Total amount of fees paid to insurance company	USD $2,605
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $192,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,068
Amount paid for insurance broker fees	2605
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468-000/800

Policy instance

Insurance contract or identification number	1009468-000/800
Number of Individuals Covered	8
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $319
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $319
Insurance broker organization code?	3
Insurance broker name	MICHAEL GRANT

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

887369

Policy instance

Insurance contract or identification number	887369
Number of Individuals Covered	175
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,983
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,983
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	89
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $693
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $693
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	145
Insurance policy start date	2012-02-01
Insurance policy end date	2013-02-01
Total amount of commissions paid to insurance broker	USD $22,343
Total amount of fees paid to insurance company	USD $2,132
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,343
Amount paid for insurance broker fees	2132
Additional information about fees paid to insurance broker	PLAN ADMINISTRATION
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468-000/800

Policy instance

Insurance contract or identification number	1009468-000/800
Number of Individuals Covered	8
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $489
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $489
Insurance broker organization code?	3
Insurance broker name	MICHAEL GRANT

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY004098

Policy instance

Insurance contract or identification number	ABY004098
Insurance policy start date	2012-05-01
Insurance policy end date	2013-05-01
Total amount of commissions paid to insurance broker	USD $236
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $236
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

887369

Policy instance

Insurance contract or identification number	887369
Number of Individuals Covered	171
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,344
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,344
Insurance broker organization code?	3
Insurance broker name	USI INSURANCE SERVICES LLC

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468-000/800

Policy instance

Insurance contract or identification number	1009468-000/800
Number of Individuals Covered	10
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $596
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	136
Insurance policy start date	2011-02-01
Insurance policy end date	2012-02-01
Total amount of commissions paid to insurance broker	USD $22,765
Total amount of fees paid to insurance company	USD $2,190
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $174,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	89
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $712
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY004098

Policy instance

Insurance contract or identification number	ABY004098
Insurance policy start date	2011-05-01
Insurance policy end date	2012-05-01
Total amount of commissions paid to insurance broker	USD $527
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

887369

Policy instance

Insurance contract or identification number	887369
Number of Individuals Covered	178
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,846
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

564952

Policy instance

Insurance contract or identification number	564952
Number of Individuals Covered	139
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $19,151
Total amount of fees paid to insurance company	USD $1,902
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $166,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 55247 )

Policy contract number

1009468-000/800

Policy instance

Insurance contract or identification number	1009468-000/800
Number of Individuals Covered	15
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $453
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

887369

Policy instance

Insurance contract or identification number	887369
Number of Individuals Covered	282
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $3,303
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $64,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12229883

Policy instance

Insurance contract or identification number	12229883
Number of Individuals Covered	94
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $702
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )

Policy contract number

ABY004098

Policy instance

Insurance contract or identification number	ABY004098
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $476
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95234 )

Policy contract number

US093893

Policy instance

Insurance contract or identification number	US093893
Number of Individuals Covered	207
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $34,171
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $1,130,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	NATIONAL URBAN LEAGUE
Employer identification number (EIN):	131840489
NAIC Classification:	813000
NAIC Description:	Religious, Grantmaking, Civic, Professional, and Similar Organizations