COLUMBIA MEMORIAL HOSPITAL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan COLUMBIA MEMORIAL HOSPITAL GROUP HEALTH PLAN
| Measure | Date | Value |
|---|
| 2022: COLUMBIA MEMORIAL HOSPITAL GROUP HEALTH PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-01 | 1,096 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 1,004 |
| Number of retired or separated participants receiving benefits | 2022-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
| Total of all active and inactive participants | 2022-06-01 | 1,004 |
| Number of employers contributing to the scheme | 2022-06-01 | 0 |
| 2021: COLUMBIA MEMORIAL HOSPITAL GROUP HEALTH PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-06-01 | 1,096 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 1,096 |
| Number of retired or separated participants receiving benefits | 2021-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-06-01 | 0 |
| Total of all active and inactive participants | 2021-06-01 | 1,096 |
| Number of employers contributing to the scheme | 2021-06-01 | 0 |
| 2020: COLUMBIA MEMORIAL HOSPITAL GROUP HEALTH PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-06-01 | 1,162 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 1,096 |
| Number of retired or separated participants receiving benefits | 2020-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-06-01 | 0 |
| Total of all active and inactive participants | 2020-06-01 | 1,096 |
| Number of employers contributing to the scheme | 2020-06-01 | 0 |
| 2019: COLUMBIA MEMORIAL HOSPITAL GROUP HEALTH PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-06-01 | 1,090 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 1,162 |
| Number of retired or separated participants receiving benefits | 2019-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-06-01 | 0 |
| Total of all active and inactive participants | 2019-06-01 | 1,162 |
| Number of employers contributing to the scheme | 2019-06-01 | 0 |
| 2018: COLUMBIA MEMORIAL HOSPITAL GROUP HEALTH PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-01 | 1,097 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 1,090 |
| Number of retired or separated participants receiving benefits | 2018-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
| Total of all active and inactive participants | 2018-06-01 | 1,090 |
| Number of employers contributing to the scheme | 2018-06-01 | 0 |
| 2017: COLUMBIA MEMORIAL HOSPITAL GROUP HEALTH PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-01 | 1,020 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 1,099 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 0 |
| Total of all active and inactive participants | 2017-06-01 | 1,105 |
| Number of employers contributing to the scheme | 2017-06-01 | 0 |
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 933516 |
| Policy instance | 5 |
| Insurance contract or identification number | 933516 | | Number of Individuals Covered | 1004 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $14,324 | | Total amount of fees paid to insurance company | USD $8,537 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $301,344 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,324 | | Amount paid for insurance broker fees | 8537 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10010052 |
| Policy instance | 4 |
| Insurance contract or identification number | 10010052 | | Number of Individuals Covered | 1061 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $215,981 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,739,251 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $215,981 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213891 0001 |
| Policy instance | 3 |
| Insurance contract or identification number | 213891 0001 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $7,802 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $182,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,802 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | N3802 |
| Policy instance | 2 |
| Insurance contract or identification number | N3802 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $28,071 | | Total amount of fees paid to insurance company | USD $261 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $185,523 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,342 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E3133295 |
| Policy instance | 1 |
| Insurance contract or identification number | E3133295 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $39 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E3133295 |
| Policy instance | 1 |
| Insurance contract or identification number | E3133295 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $41 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | N3802 |
| Policy instance | 2 |
| Insurance contract or identification number | N3802 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $21,089 | | Total amount of fees paid to insurance company | USD $261 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $186,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,961 | | Amount paid for insurance broker fees | 211 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213891 0001 |
| Policy instance | 3 |
| Insurance contract or identification number | 213891 0001 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $9,219 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $255,421 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $9,219 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10010052 |
| Policy instance | 4 |
| Insurance contract or identification number | 10010052 | | Number of Individuals Covered | 1092 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $225,548 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,121,912 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $209,934 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 933516 |
| Policy instance | 5 |
| Insurance contract or identification number | 933516 | | Number of Individuals Covered | 1096 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $13,783 | | Total amount of fees paid to insurance company | USD $9,007 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $276,732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,783 | | Amount paid for insurance broker fees | 9007 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E3133295 |
| Policy instance | 1 |
| Insurance contract or identification number | E3133295 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $47 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | N3802 |
| Policy instance | 2 |
| Insurance contract or identification number | N3802 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $32,022 | | Total amount of fees paid to insurance company | USD $2,000 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $211,964 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,252 | | Amount paid for insurance broker fees | 1275 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 965394 |
| Policy instance | 3 |
| Insurance contract or identification number | 965394 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,634 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213891 0001 |
| Policy instance | 4 |
| Insurance contract or identification number | 213891 0001 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $10,309 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $236,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $10,309 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10010052 |
| Policy instance | 5 |
| Insurance contract or identification number | 10010052 | | Number of Individuals Covered | 1232 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $239,121 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,664,857 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $239,121 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 933516 |
| Policy instance | 6 |
| Insurance contract or identification number | 933516 | | Number of Individuals Covered | 1096 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $13,826 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $288,838 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,826 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 909101 |
| Policy instance | 7 |
| Insurance contract or identification number | 909101 | | Number of Individuals Covered | 1096 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $894 | | Total amount of fees paid to insurance company | USD $181 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $31,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $894 | | Amount paid for insurance broker fees | 181 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 909104 |
| Policy instance | 7 |
| Insurance contract or identification number | 909104 | | Number of Individuals Covered | 909104 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $3,467 | | Total amount of fees paid to insurance company | USD $501 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $27,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,467 | | Amount paid for insurance broker fees | 501 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 933516 |
| Policy instance | 6 |
| Insurance contract or identification number | 933516 | | Number of Individuals Covered | 1162 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $11,767 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $179,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,767 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10010052 |
| Policy instance | 5 |
| Insurance contract or identification number | 10010052 | | Number of Individuals Covered | 1315 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $193,294 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,542,518 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $193,294 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213891 0001 |
| Policy instance | 4 |
| Insurance contract or identification number | 213891 0001 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $10,993 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $267,402 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $10,993 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 965394 |
| Policy instance | 3 |
| Insurance contract or identification number | 965394 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | N3802 |
| Policy instance | 2 |
| Insurance contract or identification number | N3802 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $44,938 | | Total amount of fees paid to insurance company | USD $2,006 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $242,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,074 | | Amount paid for insurance broker fees | 1090 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E3133295 |
| Policy instance | 1 |
| Insurance contract or identification number | E3133295 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $66 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $1,391 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | E3133295 |
| Policy instance | 1 |
| Insurance contract or identification number | E3133295 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | N3802 |
| Policy instance | 2 |
| Insurance contract or identification number | N3802 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $44,563 | | Total amount of fees paid to insurance company | USD $4,717 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $219,691 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,813 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 965394 |
| Policy instance | 3 |
| Insurance contract or identification number | 965394 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10010052 |
| Policy instance | 5 |
| Insurance contract or identification number | 10010052 | | Number of Individuals Covered | 1337 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $228,671 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,246,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $228,671 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213891 |
| Policy instance | 4 |
| Insurance contract or identification number | 213891 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $12,915 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $370,012 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $12,915 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 966383 |
| Policy instance | 6 |
| Insurance contract or identification number | 966383 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 909101 |
| Policy instance | 7 |
| Insurance contract or identification number | 909101 | | Number of Individuals Covered | 1017 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $24,311 | | Total amount of fees paid to insurance company | USD $3,919 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $308,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,311 | | Amount paid for insurance broker fees | 3919 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | E3133295 |
| Policy instance | 1 |
| Insurance contract or identification number | E3133295 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $94 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $1,758 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 10010052 |
| Policy instance | 3 |
| Insurance contract or identification number | 10010052 | | Number of Individuals Covered | 1362 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $217,411 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,796,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 5889 |
| Policy instance | 4 |
| Insurance contract or identification number | 5889 | | Number of Individuals Covered | 1883 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $144,733 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 909101 |
| Policy instance | 5 |
| Insurance contract or identification number | 909101 | | Number of Individuals Covered | 1034 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $30,249 | | Total amount of fees paid to insurance company | USD $5,380 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $378,801 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC (National Association of Insurance Commissioners NAIC id number: 95491 ) |
| Policy contract number | 213891 |
| Policy instance | 7 |
| Insurance contract or identification number | 213891 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $54,038 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $920,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 965394 |
| Policy instance | 6 |
| Insurance contract or identification number | 965394 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,928 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | N3802 |
| Policy instance | 2 |
| Insurance contract or identification number | N3802 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $50,819 | | Total amount of fees paid to insurance company | USD $800 | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $196,738 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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