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SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameSV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN
Plan identification number 501

SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

SV-DVS HOLDINGS, LLC has sponsored the creation of one or more 401k plans.

Company Name:SV-DVS HOLDINGS, LLC
Employer identification number (EIN):134281982
NAIC Classification:541600

Additional information about SV-DVS HOLDINGS, LLC

Jurisdiction of Incorporation: Georgia Department of States Corporations Division
Incorporation Date:
Company Identification Number: 1571545

More information about SV-DVS HOLDINGS, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-08-01
5012021-08-01
5012020-08-01
5012019-08-01
5012018-08-01
5012017-08-01ANNE RAVERT
5012016-08-01ANNE RAVERT
5012015-08-01ANNE RAVERT

Plan Statistics for SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-08-01248
Total number of active participants reported on line 7a of the Form 55002022-08-01303
Number of retired or separated participants receiving benefits2022-08-0111
Number of other retired or separated participants entitled to future benefits2022-08-010
Total of all active and inactive participants2022-08-01314
2021: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-08-01227
Total number of active participants reported on line 7a of the Form 55002021-08-01248
Number of retired or separated participants receiving benefits2021-08-017
Number of other retired or separated participants entitled to future benefits2021-08-010
Total of all active and inactive participants2021-08-01255
2020: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-08-01230
Total number of active participants reported on line 7a of the Form 55002020-08-01288
Number of retired or separated participants receiving benefits2020-08-015
Number of other retired or separated participants entitled to future benefits2020-08-010
Total of all active and inactive participants2020-08-01293
2019: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-08-01135
Total number of active participants reported on line 7a of the Form 55002019-08-01126
Number of retired or separated participants receiving benefits2019-08-012
Number of other retired or separated participants entitled to future benefits2019-08-010
Total of all active and inactive participants2019-08-01128
2018: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01138
Total number of active participants reported on line 7a of the Form 55002018-08-01135
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 participants2018-08-01136
2017: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01133
Total number of active participants reported on line 7a of the Form 55002017-08-01138
Number of retired or separated participants receiving benefits2017-08-011
Number of other retired or separated participants entitled to future benefits2017-08-010
Total of all active and inactive participants2017-08-01139
2016: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01125
Total number of active participants reported on line 7a of the Form 55002016-08-01134
Number of retired or separated participants receiving benefits2016-08-012
Number of other retired or separated participants entitled to future benefits2016-08-010
Total of all active and inactive participants2016-08-01136
2015: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-08-01115
Total number of active participants reported on line 7a of the Form 55002015-08-01125
Number of retired or separated participants receiving benefits2015-08-015
Number of other retired or separated participants entitled to future benefits2015-08-010
Total of all active and inactive participants2015-08-01130

Form 5500 Responses for SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN

2022: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-08-01Type of plan entitySingle employer plan
2022-08-01Submission has been amendedNo
2022-08-01This submission is the final filingNo
2022-08-01This return/report is a short plan year return/report (less than 12 months)No
2022-08-01Plan is a collectively bargained planNo
2022-08-01Plan funding arrangement – InsuranceYes
2022-08-01Plan funding arrangement – General assets of the sponsorYes
2022-08-01Plan benefit arrangement – InsuranceYes
2022-08-01Plan benefit arrangement – General assets of the sponsorYes
2021: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-08-01Type of plan entitySingle employer plan
2021-08-01Submission has been amendedNo
2021-08-01This submission is the final filingNo
2021-08-01This return/report is a short plan year return/report (less than 12 months)No
2021-08-01Plan is a collectively bargained planNo
2021-08-01Plan funding arrangement – InsuranceYes
2021-08-01Plan funding arrangement – General assets of the sponsorYes
2021-08-01Plan benefit arrangement – InsuranceYes
2021-08-01Plan benefit arrangement – General assets of the sponsorYes
2020: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-08-01Type of plan entitySingle employer plan
2020-08-01Submission has been amendedNo
2020-08-01This submission is the final filingNo
2020-08-01This return/report is a short plan year return/report (less than 12 months)No
2020-08-01Plan is a collectively bargained planNo
2020-08-01Plan funding arrangement – InsuranceYes
2020-08-01Plan funding arrangement – General assets of the sponsorYes
2020-08-01Plan benefit arrangement – InsuranceYes
2020-08-01Plan benefit arrangement – General assets of the sponsorYes
2019: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Submission has been amendedNo
2019-08-01This submission is the final filingNo
2019-08-01This return/report is a short plan year return/report (less than 12 months)No
2019-08-01Plan is a collectively bargained planNo
2019-08-01Plan funding arrangement – InsuranceYes
2019-08-01Plan funding arrangement – General assets of the sponsorYes
2019-08-01Plan benefit arrangement – InsuranceYes
2019-08-01Plan benefit arrangement – General assets of the sponsorYes
2018: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Submission has been amendedNo
2018-08-01This submission is the final filingNo
2018-08-01This return/report is a short plan year return/report (less than 12 months)No
2018-08-01Plan is a collectively bargained planNo
2018-08-01Plan funding arrangement – InsuranceYes
2018-08-01Plan funding arrangement – General assets of the sponsorYes
2018-08-01Plan benefit arrangement – InsuranceYes
2018-08-01Plan benefit arrangement – General assets of the sponsorYes
2017: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Submission has been amendedNo
2017-08-01This submission is the final filingNo
2017-08-01This return/report is a short plan year return/report (less than 12 months)No
2017-08-01Plan is a collectively bargained planNo
2017-08-01Plan funding arrangement – InsuranceYes
2017-08-01Plan funding arrangement – General assets of the sponsorYes
2017-08-01Plan benefit arrangement – InsuranceYes
2017-08-01Plan benefit arrangement – General assets of the sponsorYes
2016: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS 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 funding arrangement – General assets of the sponsorYes
2016-08-01Plan benefit arrangement – InsuranceYes
2016-08-01Plan benefit arrangement – General assets of the sponsorYes
2015: SV-DVS HOLDINGS, LLC EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-08-01Type of plan entitySingle employer plan
2015-08-01First time form 5500 has been submittedYes
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 funding arrangement – General assets of the sponsorYes
2015-08-01Plan benefit arrangement – InsuranceYes
2015-08-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BQZ4
Policy instance 5
Insurance contract or identification numberG000BQZ4
Number of Individuals Covered329
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $17,968
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT
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 $288,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,968
Insurance broker organization code?3
SHELTERPOINT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 89958 )
Policy contract numberGVPA28164
Policy instance 4
Insurance contract or identification numberGVPA28164
Number of Individuals Covered223
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $2,297
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,723
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number896579
Policy instance 3
Insurance contract or identification number896579
Number of Individuals Covered472
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $13,144
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $238,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,144
Insurance broker organization code?3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0002620561
Policy instance 2
Insurance contract or identification number0002620561
Number of Individuals Covered414
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $31,603
Total amount of fees paid to insurance companyUSD $3,811
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,603
Amount paid for insurance broker fees3811
Additional information about fees paid to insurance brokerOVERRIDE, NON MONETARY COMMISSIONS
Insurance broker organization code?3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0002620561
Policy instance 1
Insurance contract or identification number0002620561
Number of Individuals Covered414
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $157,193
Total amount of fees paid to insurance companyUSD $3,811
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $157,193
Amount paid for insurance broker fees3811
Additional information about fees paid to insurance brokerOVERRIDE, NON MONETARY COMMISSIONS
Insurance broker organization code?3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0002620561
Policy instance 1
Insurance contract or identification number0002620561
Number of Individuals Covered457
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $141,175
Total amount of fees paid to insurance companyUSD $4,442
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $141,175
Amount paid for insurance broker fees4442
Additional information about fees paid to insurance brokerOVERRIDE, NON MONETARY COMMISSIONS
Insurance broker organization code?3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0002620561
Policy instance 2
Insurance contract or identification number0002620561
Number of Individuals Covered457
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $32,418
Total amount of fees paid to insurance companyUSD $4,442
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,418
Amount paid for insurance broker fees4442
Additional information about fees paid to insurance brokerOVERRIDE, NON MONETARY COMMISSIONS
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number896579
Policy instance 3
Insurance contract or identification number896579
Number of Individuals Covered525
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $18,032
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $211,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,032
Insurance broker organization code?3
SHELTERPOINT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 89958 )
Policy contract numberGVPA28164
Policy instance 4
Insurance contract or identification numberGVPA28164
Number of Individuals Covered243
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $2,338
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,338
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BQZ4
Policy instance 5
Insurance contract or identification numberG000BQZ4
Number of Individuals Covered339
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $15,912
Total amount of fees paid to insurance companyUSD $4,437
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT
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 $256,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,912
Amount paid for insurance broker fees4437
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0002620561
Policy instance 1
Insurance contract or identification number0002620561
Number of Individuals Covered216
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $84,901
Total amount of fees paid to insurance companyUSD $14,970
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $84,901
Amount paid for insurance broker fees14970
Additional information about fees paid to insurance brokerOVERRIDE, NON MONETARY COMMISSIONS
Insurance broker organization code?3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0002620561
Policy instance 2
Insurance contract or identification number0002620561
Number of Individuals Covered216
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $22,300
Total amount of fees paid to insurance companyUSD $8,710
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,300
Amount paid for insurance broker fees8710
Additional information about fees paid to insurance brokerOVERRIDE, NON MONETARY COMMISSIONS
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number896579
Policy instance 3
Insurance contract or identification number896579
Number of Individuals Covered241
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $16,539
Total amount of fees paid to insurance companyUSD $2,798
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $183,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,539
Amount paid for insurance broker fees2798
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
SHELTERPOINT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 89958 )
Policy contract numberGVPA28164
Policy instance 4
Insurance contract or identification numberGVPA28164
Number of Individuals Covered233
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $2,246
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,246
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BQZ4
Policy instance 5
Insurance contract or identification numberG000BQZ4
Number of Individuals Covered279
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $15,040
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT
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 $223,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,753
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number218726
Policy instance 7
Insurance contract or identification number218726
Number of Individuals Covered29
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $2,674
Total amount of fees paid to insurance companyUSD $169
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $16,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,674
Amount paid for insurance broker fees169
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 122039
Policy instance 6
Insurance contract or identification numberLTD 122039
Number of Individuals Covered145
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $7,240
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare 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 $53,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,567
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 161733
Policy instance 5
Insurance contract or identification numberG 161733
Number of Individuals Covered145
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $3,580
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,378
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 148504
Policy instance 4
Insurance contract or identification numberGL 148504
Number of Individuals Covered145
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $2,659
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,701
Insurance broker organization code?3
SHELTERPOINT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 89958 )
Policy contract numberGVPA28164
Policy instance 3
Insurance contract or identification numberGVPA28164
Number of Individuals Covered223
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $1,393
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,393
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number896579-099, 000
Policy instance 2
Insurance contract or identification number896579-099, 000
Number of Individuals Covered109
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $3,549
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $88,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,376
Insurance broker organization code?3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0001026829
Policy instance 1
Insurance contract or identification number0001026829
Number of Individuals Covered88
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $27,962
Total amount of fees paid to insurance companyUSD $10,098
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,962
Amount paid for insurance broker fees10098
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0001026829
Policy instance 1
Insurance contract or identification number0001026829
Number of Individuals Covered79
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $37,451
Total amount of fees paid to insurance companyUSD $10,770
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,451
Amount paid for insurance broker fees10770
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )
Policy contract number0001026829
Policy instance 2
Insurance contract or identification number0001026829
Number of Individuals Covered10
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $5,962
Total amount of fees paid to insurance companyUSD $1,420
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,962
Amount paid for insurance broker fees1420
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number896579-099, 000
Policy instance 3
Insurance contract or identification number896579-099, 000
Number of Individuals Covered103
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $3,045
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $76,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,045
Insurance broker organization code?3
SHELTERPOINT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 89958 )
Policy contract numberGVPA28164
Policy instance 4
Insurance contract or identification numberGVPA28164
Number of Individuals Covered100
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $1,262
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,262
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 148504
Policy instance 5
Insurance contract or identification numberGL 148504
Number of Individuals Covered135
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $2,558
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,640
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 161733
Policy instance 6
Insurance contract or identification numberG 161733
Number of Individuals Covered135
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $3,468
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,308
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 122039
Policy instance 7
Insurance contract or identification numberLTD 122039
Number of Individuals Covered135
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $7,100
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare 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 $51,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,529
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number218726
Policy instance 8
Insurance contract or identification number218726
Number of Individuals Covered25
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $1,800
Total amount of fees paid to insurance companyUSD $150
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,800
Amount paid for insurance broker fees150
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )
Policy contract number0001026829
Policy instance 2
Insurance contract or identification number0001026829
Number of Individuals Covered12
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $6,715
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,715
Insurance broker organization code?3
Insurance broker nameEMERSON REID DBA TRA BENEFIT
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number896579-099, 000
Policy instance 3
Insurance contract or identification number896579-099, 000
Number of Individuals Covered92
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $7,452
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $74,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,452
Insurance broker organization code?3
Insurance broker nameEMERSON REID DBA TRA BENEFIT
SHELTERPOINT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 89958 )
Policy contract numberGVPA28164
Policy instance 4
Insurance contract or identification numberGVPA28164
Number of Individuals Covered85
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $1,327
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,327
Insurance broker organization code?3
Insurance broker nameEMERSON REID LLC EMERSON REID & CO
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 148504
Policy instance 5
Insurance contract or identification numberGL 148504
Number of Individuals Covered124
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $2,483
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedBASIC GROUP TERM LIFE, AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,599
Insurance broker organization code?3
Insurance broker nameEMERSON REID & CO.
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 161733
Policy instance 6
Insurance contract or identification numberG 161733
Number of Individuals Covered124
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $3,298
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,203
Insurance broker organization code?3
Insurance broker nameEMERSON REID & CO.
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 122039
Policy instance 7
Insurance contract or identification numberLTD 122039
Number of Individuals Covered124
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $6,908
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare 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 $49,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,454
Insurance broker organization code?3
Insurance broker nameEMERSON REID & CO.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number218726
Policy instance 8
Insurance contract or identification number218726
Number of Individuals Covered18
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $2,665
Total amount of fees paid to insurance companyUSD $222
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,665
Amount paid for insurance broker fees222
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameLEON L LEVY & ASSOCIATES INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number218726
Policy instance 9
Insurance contract or identification number218726
Number of Individuals Covered18
Insurance policy start date2018-04-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $603
Total amount of fees paid to insurance companyUSD $50
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $603
Amount paid for insurance broker fees50
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameLEON L LEVY & ASSOCIATES INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number218726
Policy instance 10
Insurance contract or identification number218726
Number of Individuals Covered18
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $2,601
Total amount of fees paid to insurance companyUSD $217
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,342
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,601
Amount paid for insurance broker fees217
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameLEON L LEVY & ASSOCIATES INC
INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )
Policy contract number0001026829
Policy instance 1
Insurance contract or identification number0001026829
Number of Individuals Covered73
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $44,879
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,879
Insurance broker organization code?3
Insurance broker nameEMERSON REID DBA TRA BENEFIT

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