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MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 401k Plan overview

Plan NameMIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN
Plan identification number 501

MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT 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)
  • 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

MIKIMOTO AMERICA COMPANY LTD has sponsored the creation of one or more 401k plans.

Company Name:MIKIMOTO AMERICA COMPANY LTD
Employer identification number (EIN):132932680
NAIC Classification:448310
NAIC Description:Jewelry Stores

Additional information about MIKIMOTO AMERICA COMPANY LTD

Jurisdiction of Incorporation: New York Department of State
Incorporation Date: 1978-02-27
Company Identification Number: 474156
Legal Registered Office Address: 1185 AVENUE OF THE AMERICAS
SUITE 3000
NEW YORK
United States of America (USA)
10036

More information about MIKIMOTO AMERICA COMPANY LTD

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012019-08-01PANTELIS MARKOU2020-12-29
5012019-08-01PANTELIS MARKOU2022-01-21
5012018-08-01PANTELIS MARKOU2020-01-22
5012017-08-01
5012016-08-01
5012015-08-01ROSANNA ALBASESE
5012015-08-01
5012014-08-01ROSANNA ALBARGE
5012013-08-01ROSANNA ALBANESE
5012012-08-01ROSANNA ALBANESE
5012011-08-01ROSANNA ALBANESE
5012009-08-01YOZO NISHII
5012008-08-01YOZO NISHII

Plan Statistics for MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN

401k plan membership statisitcs for MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN

Measure Date Value
2019: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-08-01101
Total number of active participants reported on line 7a of the Form 55002019-08-01152
Number of retired or separated participants receiving benefits2019-08-010
Number of other retired or separated participants entitled to future benefits2019-08-010
Total of all active and inactive participants2019-08-01152
Number of employers contributing to the scheme2019-08-010
2018: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01101
Total number of active participants reported on line 7a of the Form 55002018-08-01101
Number of retired or separated participants receiving benefits2018-08-011
Number of other retired or separated participants entitled to future benefits2018-08-010
Total of all active and inactive participants2018-08-01102
Number of employers contributing to the scheme2018-08-010
2017: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01101
Total number of active participants reported on line 7a of the Form 55002017-08-01101
Number of retired or separated participants receiving benefits2017-08-010
Number of other retired or separated participants entitled to future benefits2017-08-011
Total of all active and inactive participants2017-08-01102
Number of employers contributing to the scheme2017-08-010
2016: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01108
Total number of active participants reported on line 7a of the Form 55002016-08-0197
Number of retired or separated participants receiving benefits2016-08-010
Number of other retired or separated participants entitled to future benefits2016-08-010
Total of all active and inactive participants2016-08-0197
2015: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-08-01101
Total number of active participants reported on line 7a of the Form 55002015-08-01108
Number of retired or separated participants receiving benefits2015-08-010
Number of other retired or separated participants entitled to future benefits2015-08-010
Total of all active and inactive participants2015-08-01108
2014: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-08-01101
Total number of active participants reported on line 7a of the Form 55002014-08-01101
Number of retired or separated participants receiving benefits2014-08-010
Number of other retired or separated participants entitled to future benefits2014-08-010
Total of all active and inactive participants2014-08-01101
2013: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-08-01100
Total number of active participants reported on line 7a of the Form 55002013-08-01101
Number of retired or separated participants receiving benefits2013-08-010
Number of other retired or separated participants entitled to future benefits2013-08-010
Total of all active and inactive participants2013-08-01101
2012: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-08-01100
Total number of active participants reported on line 7a of the Form 55002012-08-01101
Number of retired or separated participants receiving benefits2012-08-010
Number of other retired or separated participants entitled to future benefits2012-08-010
Total of all active and inactive participants2012-08-01101
2011: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-08-01101
Total number of active participants reported on line 7a of the Form 55002011-08-01100
Number of retired or separated participants receiving benefits2011-08-010
Number of other retired or separated participants entitled to future benefits2011-08-010
Total of all active and inactive participants2011-08-01100
2009: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-08-01115
Total number of active participants reported on line 7a of the Form 55002009-08-0192
Number of retired or separated participants receiving benefits2009-08-010
Number of other retired or separated participants entitled to future benefits2009-08-010
Total of all active and inactive participants2009-08-0192
2008: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year2008-08-01121
Total number of active participants reported on line 7a of the Form 55002008-08-01115
Number of retired or separated participants receiving benefits2008-08-010
Number of other retired or separated participants entitled to future benefits2008-08-010
Total of all active and inactive participants2008-08-01115

Form 5500 Responses for MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN

2019: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Submission has been amendedYes
2019-08-01Plan funding arrangement – InsuranceYes
2019-08-01Plan benefit arrangement – InsuranceYes
2018: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Plan funding arrangement – InsuranceYes
2018-08-01Plan benefit arrangement – InsuranceYes
2017: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Plan funding arrangement – InsuranceYes
2017-08-01Plan benefit arrangement – InsuranceYes
2016: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2016 form 5500 responses
2016-08-01Type of plan entitySingle employer plan
2016-08-01Submission has been amendedNo
2016-08-01This submission is the final filingNo
2016-08-01This return/report is a short plan year return/report (less than 12 months)No
2016-08-01Plan is a collectively bargained planNo
2016-08-01Plan funding arrangement – InsuranceYes
2016-08-01Plan benefit arrangement – InsuranceYes
2015: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2015 form 5500 responses
2015-08-01Type of plan entitySingle employer plan
2015-08-01Submission has been amendedNo
2015-08-01This submission is the final filingNo
2015-08-01This return/report is a short plan year return/report (less than 12 months)No
2015-08-01Plan is a collectively bargained planNo
2015-08-01Plan funding arrangement – InsuranceYes
2015-08-01Plan benefit arrangement – InsuranceYes
2014: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2014 form 5500 responses
2014-08-01Type of plan entitySingle employer plan
2014-08-01Submission has been amendedNo
2014-08-01This submission is the final filingNo
2014-08-01This return/report is a short plan year return/report (less than 12 months)No
2014-08-01Plan is a collectively bargained planNo
2014-08-01Plan funding arrangement – InsuranceYes
2014-08-01Plan benefit arrangement – InsuranceYes
2013: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2013 form 5500 responses
2013-08-01Type of plan entitySingle employer plan
2013-08-01Submission has been amendedNo
2013-08-01This submission is the final filingNo
2013-08-01This return/report is a short plan year return/report (less than 12 months)No
2013-08-01Plan is a collectively bargained planNo
2013-08-01Plan funding arrangement – InsuranceYes
2013-08-01Plan benefit arrangement – InsuranceYes
2012: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2012 form 5500 responses
2012-08-01Type of plan entitySingle employer plan
2012-08-01Submission has been amendedNo
2012-08-01This submission is the final filingNo
2012-08-01This return/report is a short plan year return/report (less than 12 months)No
2012-08-01Plan is a collectively bargained planNo
2012-08-01Plan funding arrangement – InsuranceYes
2012-08-01Plan benefit arrangement – InsuranceYes
2011: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2011 form 5500 responses
2011-08-01Type of plan entitySingle employer plan
2011-08-01Submission has been amendedNo
2011-08-01This submission is the final filingNo
2011-08-01This return/report is a short plan year return/report (less than 12 months)No
2011-08-01Plan is a collectively bargained planNo
2011-08-01Plan funding arrangement – InsuranceYes
2011-08-01Plan benefit arrangement – InsuranceYes
2009: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2009 form 5500 responses
2009-08-01Type of plan entitySingle employer plan
2009-08-01Submission has been amendedNo
2009-08-01This submission is the final filingNo
2009-08-01This return/report is a short plan year return/report (less than 12 months)No
2009-08-01Plan is a collectively bargained planNo
2009-08-01Plan funding arrangement – InsuranceYes
2009-08-01Plan benefit arrangement – InsuranceYes
2008: MIKIMOTO AMERICA COMPANY LTD EMPLOYER SPONSORED FRINGE BENEFIT PLAN 2008 form 5500 responses
2008-08-01Type of plan entitySingle employer plan
2008-08-01Submission has been amendedNo
2008-08-01This submission is the final filingNo
2008-08-01This return/report is a short plan year return/report (less than 12 months)No
2008-08-01Plan is a collectively bargained planNo
2008-08-01Plan funding arrangement – InsuranceYes
2008-08-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )
Policy contract numberGVNY3560
Policy instance 2
Insurance contract or identification numberGVNY3560
Number of Individuals Covered75
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $1,069
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,910
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,069
Amount paid for insurance broker fees0
Insurance broker organization code?3
ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 )
Policy contract numberAL00004997
Policy instance 1
Insurance contract or identification numberAL00004997
Number of Individuals Covered85
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $1,557
Total amount of fees paid to insurance companyUSD $114
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $11,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,557
Amount paid for insurance broker fees114
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number378329
Policy instance 3
Insurance contract or identification number378329
Number of Individuals Covered152
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $40,950
Total amount of fees paid to insurance companyUSD $1,410
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,848,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,950
Amount paid for insurance broker fees1410
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number472511
Policy instance 4
Insurance contract or identification number472511
Number of Individuals Covered183
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $5,558
Total amount of fees paid to insurance companyUSD $83
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $133,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,558
Amount paid for insurance broker fees83
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10106227
Policy instance 5
Insurance contract or identification number10106227
Number of Individuals Covered69
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $3,601
Total amount of fees paid to insurance companyUSD $1,529
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $26,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,601
Amount paid for insurance broker fees1410
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 )
Policy contract numberAL00004997
Policy instance 1
Insurance contract or identification numberAL00004997
Number of Individuals Covered83
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $1,505
Total amount of fees paid to insurance companyUSD $459
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $11,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,357
Amount paid for insurance broker fees459
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10106228
Policy instance 5
Insurance contract or identification number10106228
Number of Individuals Covered80
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $3,094
Total amount of fees paid to insurance companyUSD $1,217
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $22,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,094
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number472511
Policy instance 4
Insurance contract or identification number472511
Number of Individuals Covered176
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $4,855
Total amount of fees paid to insurance companyUSD $49
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $133,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,855
Amount paid for insurance broker fees49
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION
Insurance broker organization code?3
THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )
Policy contract numberGVNY3560
Policy instance 2
Insurance contract or identification numberGVNY3560
Number of Individuals Covered86
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $1,119
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,119
Amount paid for insurance broker fees0
Insurance broker organization code?3
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number378329
Policy instance 3
Insurance contract or identification number378329
Number of Individuals Covered160
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $33,312
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,463,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,312
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )
Policy contract numberGVNY3560
Policy instance 2
Insurance contract or identification numberGVNY3560
Number of Individuals Covered87
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $1,030
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10106228
Policy instance 5
Insurance contract or identification number10106228
Number of Individuals Covered73
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $2,687
Total amount of fees paid to insurance companyUSD $477
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $19,756
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 number472511
Policy instance 4
Insurance contract or identification number472511
Number of Individuals Covered181
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $5,434
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $138,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number378329
Policy instance 3
Insurance contract or identification number378329
Number of Individuals Covered156
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $78,566
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,394,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 )
Policy contract numberAL00004997
Policy instance 1
Insurance contract or identification numberAL00004997
Number of Individuals Covered82
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $1,599
Total amount of fees paid to insurance companyUSD $120
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $10,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number472511
Policy instance 2
Insurance contract or identification number472511
Number of Individuals Covered217
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $6,391
Total amount of fees paid to insurance companyUSD $856
Are there contracts with allocated funds for individual policies?No
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 $149,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,373
Amount paid for insurance broker fees742
Additional information about fees paid to insurance broker2014/2015 PPP ENGAGEMENT CREDIT
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10106227
Policy instance 5
Insurance contract or identification number10106227
Number of Individuals Covered87
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $3,732
Total amount of fees paid to insurance companyUSD $270
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $28,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,732
Insurance broker organization code?3
Amount paid for insurance broker fees270
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker nameEMERSON REID AND COMPANY, INC.
ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 )
Policy contract numberAL00004997
Policy instance 4
Insurance contract or identification numberAL00004997
Number of Individuals Covered92
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $2,070
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $14,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,070
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )
Policy contract numberGVNY3560
Policy instance 3
Insurance contract or identification numberGVNY3560
Number of Individuals Covered422
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,254
Are there contracts with allocated funds for individual policies?No
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
Welfare Benefit Premiums Paid to CarrierUSD $10,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,254
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number378329
Policy instance 1
Insurance contract or identification number378329
Number of Individuals Covered194
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $40,480
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $2,963,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,480
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number378329
Policy instance 1
Insurance contract or identification number378329
Number of Individuals Covered195
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $30,917
Total amount of fees paid to insurance companyUSD $980
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $882,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,917
Amount paid for insurance broker fees980
Additional information about fees paid to insurance brokerFEES
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 number472511
Policy instance 2
Insurance contract or identification number472511
Number of Individuals Covered212
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $5,429
Total amount of fees paid to insurance companyUSD $1,750
Are there contracts with allocated funds for individual policies?No
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 $137,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,429
Amount paid for insurance broker fees1750
Additional information about fees paid to insurance broker2013/2013 MM P3 BONUS
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )
Policy contract numberGVNY3560
Policy instance 3
Insurance contract or identification numberGVNY3560
Number of Individuals Covered422
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $1,236
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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
Welfare Benefit Premiums Paid to CarrierUSD $10,296
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,236
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 )
Policy contract numberAL00004997
Policy instance 4
Insurance contract or identification numberAL00004997
Number of Individuals Covered95
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $2,333
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $14,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,333
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10106227
Policy instance 5
Insurance contract or identification number10106227
Number of Individuals Covered95
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $3,457
Total amount of fees paid to insurance companyUSD $1,652
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $25,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,457
Insurance broker organization code?3
Amount paid for insurance broker fees1652
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker nameEMERSON REID AND COMPANY, INC.
THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )
Policy contract numberGVNY3560
Policy instance 3
Insurance contract or identification numberGVNY3560
Number of Individuals Covered403
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $1,366
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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
Welfare Benefit Premiums Paid to CarrierUSD $11,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,366
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number378329
Policy instance 1
Insurance contract or identification number378329
Number of Individuals Covered188
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $28,673
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $1,016,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,673
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 number472511
Policy instance 2
Insurance contract or identification number472511
Number of Individuals Covered207
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $4,685
Total amount of fees paid to insurance companyUSD $141
Are there contracts with allocated funds for individual policies?No
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 $128,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,477
Insurance broker organization code?3
Amount paid for insurance broker fees141
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION
Insurance broker nameUSI INSURANCE SERVICES, LLC
ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 )
Policy contract numberAL00004997
Policy instance 5
Insurance contract or identification numberAL00004997
Number of Individuals Covered95
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $787
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $13,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $787
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10106227
Policy instance 4
Insurance contract or identification number10106227
Number of Individuals Covered92
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $3,079
Total amount of fees paid to insurance companyUSD $288
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $22,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,079
Amount paid for insurance broker fees288
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number378329
Policy instance 1
Insurance contract or identification number378329
Number of Individuals Covered190
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $41,471
Total amount of fees paid to insurance companyUSD $6,720
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $1,146,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,471
Amount paid for insurance broker fees6720
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10106226
Policy instance 4
Insurance contract or identification number10106226
Number of Individuals Covered90
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $5,191
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 providedACCIDENTAL DEATH AND 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 $40,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,191
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )
Policy contract numberGVNY3560
Policy instance 3
Insurance contract or identification numberGVNY3560
Number of Individuals Covered359
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,407
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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
Welfare Benefit Premiums Paid to CarrierUSD $11,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,407
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 number472511
Policy instance 2
Insurance contract or identification number472511
Number of Individuals Covered203
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $4,473
Total amount of fees paid to insurance companyUSD $50
Are there contracts with allocated funds for individual policies?No
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 $112,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,473
Insurance broker organization code?3
Amount paid for insurance broker fees50
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION
Insurance broker nameUSI INSURANCE SERVICES, LLC
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10106226
Policy instance 4
Insurance contract or identification number10106226
Number of Individuals Covered92
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $4,892
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 providedACCIDENTAL DEATH AND 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 $37,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE FIRST REHABILITATION LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 81434 )
Policy contract numberGVNY3560
Policy instance 3
Insurance contract or identification numberGVNY3560
Number of Individuals Covered110
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $1,278
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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
Welfare Benefit Premiums Paid to CarrierUSD $10,648
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 number472511
Policy instance 2
Insurance contract or identification number472511
Number of Individuals Covered205
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $4,028
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 $95,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number378329
Policy instance 1
Insurance contract or identification number378329
Number of Individuals Covered193
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $39,994
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $912,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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