EMERGENT BIOSOLUTIONS has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 1,842 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 2,217 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 2,217 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 1,686 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 1,842 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 1,842 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 1,004 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 1,686 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 1,686 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 1,040 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 1,004 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 1,004 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 1,004 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 1,029 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 1,040 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 1,050 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 987 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 17 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 1,004 |
| 2016: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 1,048 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 825 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 225 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 1,050 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2016-01-01 | 0 |
| 2015: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 955 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 939 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 17 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 956 |
| 2014: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 839 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 938 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 19 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 957 |
| 2013: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 805 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 828 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 839 |
| 2012: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 755 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 830 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 839 |
| 2011: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 586 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 755 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 12 |
| Total of all active and inactive participants | 2011-01-01 | 767 |
| 2022: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | Yes |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: EMERGENT BIOSOLUTIONS INC EMPLOYEE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G0577 |
| Policy instance | 8 |
| Insurance contract or identification number | G0577 | | Number of Individuals Covered | 704 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $21,900 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | 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 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $320,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,739 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 18915 |
| Policy instance | 1 |
| Insurance contract or identification number | 18915 | | Number of Individuals Covered | 3926 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $19,483 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,224,082 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,483 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 64097099 |
| Policy instance | 2 |
| Insurance contract or identification number | 64097099 | | Number of Individuals Covered | 2217 | | Insurance policy start date | 2021-01-30 | | Insurance policy end date | 2022-01-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $346 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 346 | | Additional information about fees paid to insurance broker | CONTINGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625-1 |
| Policy instance | 3 |
| Insurance contract or identification number | 51625-1 | | Number of Individuals Covered | 1915 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $35,486 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,960,012 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $35,486 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 4 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 1554 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,992 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $216,219 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,992 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COUNSELING GLOBAL DOMESTIC (National Association of Insurance Commissioners NAIC id number: 54161 ) |
| Policy contract number | 425564 |
| Policy instance | 5 |
| Insurance contract or identification number | 425564 | | Number of Individuals Covered | 1842 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $55,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 ) |
| Policy contract number | 18202-0001-001 |
| Policy instance | 6 |
| Insurance contract or identification number | 18202-0001-001 | | Number of Individuals Covered | 988 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $10,867 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $108,669 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,867 | | 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 | 00 |
| Policy instance | 7 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 2217 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $90,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 18915 |
| Policy instance | 1 |
| Insurance contract or identification number | 18915 | | Number of Individuals Covered | 3824 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $18,725 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,180,289 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $18,725 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 64097099 |
| Policy instance | 2 |
| Insurance contract or identification number | 64097099 | | Number of Individuals Covered | 1842 | | Insurance policy start date | 2020-01-30 | | Insurance policy end date | 2021-01-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $409 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 409 | | Additional information about fees paid to insurance broker | CONTINGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625-1 |
| Policy instance | 3 |
| Insurance contract or identification number | 51625-1 | | Number of Individuals Covered | 1815 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $131,735 | | Total amount of fees paid to insurance company | USD $29,499 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,816,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $131,735 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 4 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 1513 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,179 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $210,468 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,179 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COUNSELING GLOBAL DOMESTIC (National Association of Insurance Commissioners NAIC id number: 54161 ) |
| Policy contract number | 425564 |
| Policy instance | 5 |
| Insurance contract or identification number | 425564 | | Number of Individuals Covered | 1316 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $28,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 ) |
| Policy contract number | 18202-0001-001 |
| Policy instance | 6 |
| Insurance contract or identification number | 18202-0001-001 | | Number of Individuals Covered | 950 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $10,220 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $102,201 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,220 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| TALKSPACE (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 7 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 1842 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $87,792 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G0577 |
| Policy instance | 8 |
| Insurance contract or identification number | G0577 | | Number of Individuals Covered | 709 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $22,041 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | 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 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $272,359 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,213 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 18915 |
| Policy instance | 1 |
| Insurance contract or identification number | 18915 | | Number of Individuals Covered | 3573 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $15,414 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $810,427 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $15,414 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 6409-7099 |
| Policy instance | 2 |
| Insurance contract or identification number | 6409-7099 | | Number of Individuals Covered | 1686 | | Insurance policy start date | 2019-01-30 | | Insurance policy end date | 2020-01-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $206 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 206 | | Additional information about fees paid to insurance broker | CONTINGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625 |
| Policy instance | 3 |
| Insurance contract or identification number | 51625 | | Number of Individuals Covered | 1686 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $98,836 | | Total amount of fees paid to insurance company | USD $17,199 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,303,855 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $98,836 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 4 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 1381 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,794 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $183,774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,794 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 1373 | | 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 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $10,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G0577 |
| Policy instance | 6 |
| Insurance contract or identification number | G0577 | | Number of Individuals Covered | 582 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $10,327 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $88,610 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,325 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 ) |
| Policy contract number | 18202-0001-001 |
| Policy instance | 7 |
| Insurance contract or identification number | 18202-0001-001 | | Number of Individuals Covered | 830 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $8,750 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $87,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,750 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 6409-7099 |
| Policy instance | 2 |
| Insurance contract or identification number | 6409-7099 | | Number of Individuals Covered | 2301 | | 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 $206 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 206 | | Additional information about fees paid to insurance broker | CONTINGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625 |
| Policy instance | 3 |
| Insurance contract or identification number | 51625 | | Number of Individuals Covered | 2301 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $65,914 | | Total amount of fees paid to insurance company | USD $22,242 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $808,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65,914 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 4 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 973 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,237 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $144,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,237 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 1059 | | 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 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $9,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G0577 |
| Policy instance | 6 |
| Insurance contract or identification number | G0577 | | Number of Individuals Covered | 375 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $6,259 | | Total amount of fees paid to insurance company | USD $173 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $71,666 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,525 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION |
|
| ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 ) |
| Policy contract number | 18202-0001-001 |
| Policy instance | 7 |
| Insurance contract or identification number | 18202-0001-001 | | Number of Individuals Covered | 534 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,420 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $54,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,420 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 18915 |
| Policy instance | 1 |
| Insurance contract or identification number | 18915 | | Number of Individuals Covered | 2591 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $47,048 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $940,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,048 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 18915 |
| Policy instance | 1 |
| Insurance contract or identification number | 18915 | | Number of Individuals Covered | 2372 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $43,729 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $874,585 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $40,276 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 6409-7099 |
| Policy instance | 2 |
| Insurance contract or identification number | 6409-7099 | | Number of Individuals Covered | 1671 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $155 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,553 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $155 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 4 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 906 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,027 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $126,906 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,269 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 987 | | 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 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $8,883 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G0577 |
| Policy instance | 6 |
| Insurance contract or identification number | G0577 | | Number of Individuals Covered | 430 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $9,700 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $79,982 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,892 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| GUIDEONE SPECIALTY MUTUAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14559 ) |
| Policy contract number | 18202-0001-001 |
| Policy instance | 7 |
| Insurance contract or identification number | 18202-0001-001 | | Number of Individuals Covered | 522 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $5,121 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $51,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,927 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625 |
| Policy instance | 3 |
| Insurance contract or identification number | 51625 | | Number of Individuals Covered | 1671 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $67,903 | | Total amount of fees paid to insurance company | USD $11,607 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $883,525 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $62,702 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| GUIDEONE SPECIALTY MUTUAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14559 ) |
| Policy contract number | 18202-0001-001 |
| Policy instance | 7 |
| Insurance contract or identification number | 18202-0001-001 | | Number of Individuals Covered | 412 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $3,278 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $32,783 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,278 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER H&B ADMINISTRATION LLC |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 168 |
| Policy instance | 1 |
| Insurance contract or identification number | 168 | | Number of Individuals Covered | 2212 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $40,573 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40,573 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 6409-70-99 |
| Policy instance | 2 |
| Insurance contract or identification number | 6409-70-99 | | Number of Individuals Covered | 925 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625 |
| Policy instance | 3 |
| Insurance contract or identification number | 51625 | | Number of Individuals Covered | 1575 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $64,403 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $696,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,403 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 4 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 894 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,784 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,784 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 5 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 987 | | 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 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $8,883 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G0577 |
| Policy instance | 6 |
| Insurance contract or identification number | G0577 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $4,652 | | Total amount of fees paid to insurance company | USD $584 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $23,185 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,320 | | Amount paid for insurance broker fees | 584 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITSTORE INC. |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 168 |
| Policy instance | 1 |
| Insurance contract or identification number | 168 | | Number of Individuals Covered | 2299 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $50,442 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | | 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 Broker | USD $50,442 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 6409-70-99 |
| Policy instance | 2 |
| Insurance contract or identification number | 6409-70-99 | | Number of Individuals Covered | 939 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $430 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,301 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $430 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM GALLAGHER ASSOCIATES |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625 |
| Policy instance | 3 |
| Insurance contract or identification number | 51625 | | Number of Individuals Covered | 1609 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $64,630 | | Total amount of fees paid to insurance company | USD $522 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | Were dividends or retroactive rate refunds paid in cash? | Yes | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $571,883 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,630 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 522 | | Additional information about fees paid to insurance broker | PRINTING SERVICES | | Insurance broker name | HARVARD PRINTING GROUP |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 4 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 851 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,937 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Broker | USD $2,937 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 168 |
| Policy instance | 3 |
| Insurance contract or identification number | 168 | | Number of Individuals Covered | 2314 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $38,595 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | | 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 Broker | USD $38,595 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625 |
| Policy instance | 4 |
| Insurance contract or identification number | 51625 | | Number of Individuals Covered | 1603 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $60,911 | | Total amount of fees paid to insurance company | USD $1,173 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $588,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,911 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1173 | | Additional information about fees paid to insurance broker | PRINTING SERVICES | | Insurance broker name | HARVARD PRINTING GROUP |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 6409-70-99 |
| Policy instance | 5 |
| Insurance contract or identification number | 6409-70-99 | | Number of Individuals Covered | 938 | | Insurance policy start date | 2014-05-07 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $19 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $185 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM GALLAGHER ASSOCIATES |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 6409-70-99 |
| Policy instance | 1 |
| Insurance contract or identification number | 6409-70-99 | | Number of Individuals Covered | 938 | | Insurance policy start date | 2013-05-07 | | Insurance policy end date | 2014-05-06 | | Total amount of commissions paid to insurance broker | USD $23 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $231 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM GALLAGHER ASSOCIATES |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 2 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 860 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,939 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Broker | USD $2,939 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 6409-70-99 |
| Policy instance | 1 |
| Insurance contract or identification number | 6409-70-99 | | Number of Individuals Covered | 828 | | Insurance policy start date | 2012-05-07 | | Insurance policy end date | 2013-05-06 | | Total amount of commissions paid to insurance broker | USD $610 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,050 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $610 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH USA, INC |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 168 |
| Policy instance | 3 |
| Insurance contract or identification number | 168 | | Number of Individuals Covered | 2096 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $45,459 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | | 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 Broker | USD $45,459 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 51625 |
| Policy instance | 4 |
| Insurance contract or identification number | 51625 | | Number of Individuals Covered | 828 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $54,633 | | Total amount of fees paid to insurance company | USD $904 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $546,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,633 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 904 | | Additional information about fees paid to insurance broker | PRINTING SERVICES | | Insurance broker name | HARVARD PRINTING GROUP |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 2 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 770 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,762 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Broker | USD $2,762 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 168 |
| Policy instance | 6 |
| Insurance contract or identification number | 168 | | Number of Individuals Covered | 2097 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $39,077 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | | 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 Broker | USD $39,077 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 5 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 772 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,567 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Broker | USD $2,567 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD116970 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD116970 | | Number of Individuals Covered | 730 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $25,117 | | Total amount of fees paid to insurance company | USD $1,098 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $251,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,117 | | Amount paid for insurance broker fees | 1098 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL143061 |
| Policy instance | 3 |
| Insurance contract or identification number | GL143061 | | Number of Individuals Covered | 830 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $35,693 | | Total amount of fees paid to insurance company | USD $1,396 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $356,927 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,693 | | Amount paid for insurance broker fees | 1396 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 17KA |
| Policy instance | 2 |
| Insurance contract or identification number | 17KA | | Number of Individuals Covered | 729 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $99,695 | | Total amount of fees paid to insurance company | USD $64,214 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $6,646,344 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $99,695 | | Amount paid for insurance broker fees | 64214 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 64097099 |
| Policy instance | 1 |
| Insurance contract or identification number | 64097099 | | Number of Individuals Covered | 830 | | Insurance policy start date | 2011-05-07 | | Insurance policy end date | 2012-05-06 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 17KA |
| Policy instance | 1 |
| Insurance contract or identification number | 17KA | | Number of Individuals Covered | 1758 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $84,425 | | Total amount of fees paid to insurance company | USD $123 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $5,628,341 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 168 |
| Policy instance | 2 |
| Insurance contract or identification number | 168 | | Number of Individuals Covered | 1918 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $31,410 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | | 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 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 000064097099 |
| Policy instance | 3 |
| Insurance contract or identification number | 000064097099 | | Number of Individuals Covered | 766 | | Insurance policy start date | 2010-05-07 | | Insurance policy end date | 2011-05-06 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD116970 |
| Policy instance | 5 |
| Insurance contract or identification number | LTD116970 | | Number of Individuals Covered | 656 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $21,964 | | Total amount of fees paid to insurance company | USD $1,046 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $219,638 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL143061 |
| Policy instance | 4 |
| Insurance contract or identification number | GL143061 | | Number of Individuals Covered | 755 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $27,915 | | Total amount of fees paid to insurance company | USD $1,202 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $279,146 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 6 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 701 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $2,422 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $88,457 | | 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 MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 168 |
| Policy instance | 1 |
| Insurance contract or identification number | 168 | | Number of Individuals Covered | 1502 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $23,774 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,774 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30005400 |
| Policy instance | 3 |
| Insurance contract or identification number | 30005400 | | Number of Individuals Covered | 544 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $2,167 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,794 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,167 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 64097099 |
| Policy instance | 4 |
| Insurance contract or identification number | 64097099 | | Number of Individuals Covered | 580 | | Insurance policy start date | 2009-05-07 | | Insurance policy end date | 2010-05-06 | | Total amount of commissions paid to insurance broker | USD $692 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,450 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $692 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
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| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | CLUSTER 0211 |
| Policy instance | 5 |
| Insurance contract or identification number | CLUSTER 0211 | | Number of Individuals Covered | 1367 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $60,654 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,654 | | Insurance broker organization code? | 3 | | Insurance broker name | CYNTHIA L RUSSELL |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 143061 ET AL |
| Policy instance | 2 |
| Insurance contract or identification number | GL 143061 ET AL | | Number of Individuals Covered | 572 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $44,944 | | Total amount of fees paid to insurance company | USD $1,879 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $449,435 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,944 | | Amount paid for insurance broker fees | 1879 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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