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RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 401k Plan overview

Plan NameRADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN
Plan identification number 502

RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

RADIOLOGICAL SOCIETY OF NORTH AMERICA has sponsored the creation of one or more 401k plans.

Company Name:RADIOLOGICAL SOCIETY OF NORTH AMERICA
Employer identification number (EIN):150539115
NAIC Classification:813000
NAIC Description: Religious, Grantmaking, Civic, Professional, and Similar Organizations

Form 5500 Filing Information

Submission information for form 5500 for 401k plan RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01
5022021-01-01
5022020-01-01
5022019-01-01
5022018-01-01
5022017-01-01SALLY NIKKEL SALLY NIKKEL2018-08-08
5022016-01-01SALLY A. NIKKEL SALLY A. NIKKEL2017-10-13
5022015-01-01SALLY NIKKEL SALLY NIKKEL2016-06-30
5022014-01-01SALLY NIKKEL SALLY NIKKEL2015-08-07
5022013-01-01SALLY NIKKEL SALLY NIKKEL2014-03-31
5022012-01-01SALLY NIKKEL SALLY NIKKEL2013-06-11
5022011-01-01SALLY NIKKEL SALLY NIKKEL2012-04-04
5022010-01-01SALLY NIKKEL SALLY NIKKEL2011-03-30
5022009-01-01SALLY NIKKEL SALLY NIKKEL2010-10-14

Plan Statistics for RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN

401k plan membership statisitcs for RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN

Measure Date Value
2022: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01281
Total number of active participants reported on line 7a of the Form 55002022-01-01264
Number of retired or separated participants receiving benefits2022-01-014
Number of other retired or separated participants entitled to future benefits2022-01-014
Total of all active and inactive participants2022-01-01272
2021: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01278
Total number of active participants reported on line 7a of the Form 55002021-01-01242
Number of retired or separated participants receiving benefits2021-01-011
Number of other retired or separated participants entitled to future benefits2021-01-011
Total of all active and inactive participants2021-01-01244
2020: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01270
Total number of active participants reported on line 7a of the Form 55002020-01-01235
Number of retired or separated participants receiving benefits2020-01-011
Number of other retired or separated participants entitled to future benefits2020-01-011
Total of all active and inactive participants2020-01-01237
2019: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01272
Total number of active participants reported on line 7a of the Form 55002019-01-01249
Number of retired or separated participants receiving benefits2019-01-011
Number of other retired or separated participants entitled to future benefits2019-01-011
Total of all active and inactive participants2019-01-01251
2018: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01232
Total number of active participants reported on line 7a of the Form 55002018-01-01231
Number of retired or separated participants receiving benefits2018-01-012
Number of other retired or separated participants entitled to future benefits2018-01-012
Total of all active and inactive participants2018-01-01235
2017: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01232
Total number of active participants reported on line 7a of the Form 55002017-01-01237
Number of retired or separated participants receiving benefits2017-01-013
Number of other retired or separated participants entitled to future benefits2017-01-013
Total of all active and inactive participants2017-01-01243
2016: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01215
Total number of active participants reported on line 7a of the Form 55002016-01-01214
Number of retired or separated participants receiving benefits2016-01-014
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01218
2015: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01195
Total number of active participants reported on line 7a of the Form 55002015-01-01204
Number of retired or separated participants receiving benefits2015-01-014
Total of all active and inactive participants2015-01-01208
Total participants2015-01-01208
2014: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01207
Total number of active participants reported on line 7a of the Form 55002014-01-01190
Number of retired or separated participants receiving benefits2014-01-015
Total of all active and inactive participants2014-01-01195
Total participants2014-01-01195
2013: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01189
Total number of active participants reported on line 7a of the Form 55002013-01-01201
Number of retired or separated participants receiving benefits2013-01-016
Total of all active and inactive participants2013-01-01207
Total participants2013-01-01207
2012: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01181
Total number of active participants reported on line 7a of the Form 55002012-01-01187
Number of retired or separated participants receiving benefits2012-01-012
Total of all active and inactive participants2012-01-01189
Total participants2012-01-01189
2011: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01176
Total number of active participants reported on line 7a of the Form 55002011-01-01180
Number of retired or separated participants receiving benefits2011-01-011
Total of all active and inactive participants2011-01-01181
Total participants2011-01-01181
2010: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01175
Total number of active participants reported on line 7a of the Form 55002010-01-01174
Number of retired or separated participants receiving benefits2010-01-012
Total of all active and inactive participants2010-01-01176
Total participants2010-01-01176
2009: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01166
Total number of active participants reported on line 7a of the Form 55002009-01-01173
Number of retired or separated participants receiving benefits2009-01-012
Total of all active and inactive participants2009-01-01175
Total participants2009-01-01175

Form 5500 Responses for RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN

2022: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: RADIOLOGICAL SOCIETY OF NORTH AMERICA WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 7
Insurance contract or identification number10946
Number of Individuals Covered226
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $11,035
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $240,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,035
Amount paid for insurance broker fees0
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number21706
Policy instance 1
Insurance contract or identification number21706
Number of Individuals Covered25
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $1,159
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedWORKSITE ACCIDENT, CRITICAL ILLNESS, AND HOSPITAL INDEMNITY
Welfare Benefit Premiums Paid to CarrierUSD $15,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $248
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number054348
Policy instance 2
Insurance contract or identification number054348
Number of Individuals Covered503
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $94,775
Total amount of fees paid to insurance companyUSD $2,628
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,159,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $94,775
Amount paid for insurance broker fees2628
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AQ15
Policy instance 3
Insurance contract or identification numberGLTD0AQ15
Number of Individuals Covered211
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $3,872
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $38,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,872
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902924
Policy instance 4
Insurance contract or identification number902924
Number of Individuals Covered376
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,465
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees3465
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT AND BONUS AMOUNT
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number6404-75-80
Policy instance 5
Insurance contract or identification number6404-75-80
Number of Individuals Covered592
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $50
Total amount of fees paid to insurance companyUSD $11
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50
Amount paid for insurance broker fees11
Additional information about fees paid to insurance brokerCONTINGENT COMMISSION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AQ15
Policy instance 6
Insurance contract or identification numberGLUG0AQ15
Number of Individuals Covered245
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $6,081
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $60,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,081
Amount paid for insurance broker fees0
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number21706
Policy instance 1
Insurance contract or identification number21706
Number of Individuals Covered36
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $1,156
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedWORKSITE ACCIDENT, CRITICAL ILLNESS, AND HOSPITAL INDEMNITY
Welfare Benefit Premiums Paid to CarrierUSD $20,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $280
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number054348
Policy instance 2
Insurance contract or identification number054348
Number of Individuals Covered518
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $89,218
Total amount of fees paid to insurance companyUSD $2,664
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,008,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $89,218
Amount paid for insurance broker fees2664
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AQ15
Policy instance 3
Insurance contract or identification numberGLTD0AQ15
Number of Individuals Covered218
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $3,745
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $37,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,745
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902924
Policy instance 4
Insurance contract or identification number902924
Number of Individuals Covered352
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $2,057
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,057
Amount paid for insurance broker fees0
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number6404-75-80
Policy instance 5
Insurance contract or identification number6404-75-80
Number of Individuals Covered541
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $50
Total amount of fees paid to insurance companyUSD $11
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50
Amount paid for insurance broker fees11
Additional information about fees paid to insurance brokerCONTINGENT COMMISSION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AQ15
Policy instance 6
Insurance contract or identification numberGLUG0AQ15
Number of Individuals Covered245
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $5,609
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $56,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,609
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 7
Insurance contract or identification number10946
Number of Individuals Covered233
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $11,482
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $210,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,482
Amount paid for insurance broker fees0
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number21706
Policy instance 1
Insurance contract or identification number21706
Number of Individuals Covered36
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $3,018
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedWORKSITE ACCIDENT, CRITICAL ILLNESS, AND HOSPITAL INDEMNITY
Welfare Benefit Premiums Paid to CarrierUSD $20,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $157
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number054348
Policy instance 2
Insurance contract or identification number054348
Number of Individuals Covered493
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $89,388
Total amount of fees paid to insurance companyUSD $2,496
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,005,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $89,388
Amount paid for insurance broker fees2496
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AQ15
Policy instance 3
Insurance contract or identification numberGLTD0AQ15
Number of Individuals Covered214
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $3,605
Total amount of fees paid to insurance companyUSD $1,581
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $36,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,605
Amount paid for insurance broker fees1581
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902924
Policy instance 4
Insurance contract or identification number902924
Number of Individuals Covered297
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $2,023
Total amount of fees paid to insurance companyUSD $1,104
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,023
Amount paid for insurance broker fees1104
Additional information about fees paid to insurance brokerBONUS AMOUNT
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number6404-75-80
Policy instance 5
Insurance contract or identification number6404-75-80
Number of Individuals Covered541
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $890
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $5,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $890
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AQ15
Policy instance 6
Insurance contract or identification numberGLUG0AQ15
Number of Individuals Covered238
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $5,702
Total amount of fees paid to insurance companyUSD $2,458
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $57,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,702
Amount paid for insurance broker fees2458
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 7
Insurance contract or identification number10946
Number of Individuals Covered223
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $12,240
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $244,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,240
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number21706
Policy instance 1
Insurance contract or identification number21706
Number of Individuals Covered36
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $4,996
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedWORKSITE ACCIDENT, CRITICAL ILLNESS, AND HOSPITAL INDEMNITY
Welfare Benefit Premiums Paid to CarrierUSD $19,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $541
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number054348
Policy instance 2
Insurance contract or identification number054348
Number of Individuals Covered488
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $81,477
Total amount of fees paid to insurance companyUSD $2,458
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,746,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,477
Amount paid for insurance broker fees2458
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902924
Policy instance 4
Insurance contract or identification number902924
Number of Individuals Covered122
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $1,745
Total amount of fees paid to insurance companyUSD $1,300
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,745
Amount paid for insurance broker fees1300
Additional information about fees paid to insurance brokerBONUS AMOUNT
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AQ15
Policy instance 3
Insurance contract or identification numberGLTD0AQ15
Number of Individuals Covered203
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $3,437
Total amount of fees paid to insurance companyUSD $1,979
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,437
Amount paid for insurance broker fees1979
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AQ15
Policy instance 5
Insurance contract or identification numberGLUG0AQ15
Number of Individuals Covered232
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $5,355
Total amount of fees paid to insurance companyUSD $3,165
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $53,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,355
Amount paid for insurance broker fees3165
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 6
Insurance contract or identification number10946
Number of Individuals Covered216
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $10,099
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $219,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,099
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 7
Insurance contract or identification number10946
Number of Individuals Covered215
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $10,680
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $213,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,680
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AQ15
Policy instance 6
Insurance contract or identification numberG000AQ15
Number of Individuals Covered197
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $3,176
Total amount of fees paid to insurance companyUSD $1,075
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $31,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,176
Amount paid for insurance broker fees1075
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number64047580
Policy instance 5
Insurance contract or identification number64047580
Number of Individuals Covered230
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $890
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $5,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $890
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902924
Policy instance 4
Insurance contract or identification number902924
Number of Individuals Covered231
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $1,507
Total amount of fees paid to insurance companyUSD $294
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,507
Amount paid for insurance broker fees294
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AQ15
Policy instance 3
Insurance contract or identification numberG000AQ15
Number of Individuals Covered222
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $4,890
Total amount of fees paid to insurance companyUSD $1,647
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $48,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,890
Amount paid for insurance broker fees1647
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP68849 P68850
Policy instance 2
Insurance contract or identification numberP68849 P68850
Number of Individuals Covered487
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $78,411
Total amount of fees paid to insurance companyUSD $2,412
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,674,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $78,411
Amount paid for insurance broker fees2412
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number21706
Policy instance 1
Insurance contract or identification number21706
Number of Individuals Covered23
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $1,561
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59
Insurance broker organization code?3
Insurance broker nameRUSSELL NOWAK
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP68849 P68850
Policy instance 1
Insurance contract or identification numberP68849 P68850
Number of Individuals Covered468
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $77,830
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,565,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75,412
Amount paid for insurance broker fees2418
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICE INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AQ15
Policy instance 2
Insurance contract or identification numberGLUG0AQ15
Number of Individuals Covered208
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $8,108
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $43,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,554
Amount paid for insurance broker fees1554
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract numberF3IW
Policy instance 4
Insurance contract or identification numberF3IW
Number of Individuals Covered0
Insurance policy start date2014-07-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $476
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $476
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0902924
Policy instance 5
Insurance contract or identification number0902924
Number of Individuals Covered100
Insurance policy start date2014-09-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $1,462
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,181
Amount paid for insurance broker fees281
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AQ15
Policy instance 6
Insurance contract or identification numberGLTD0AQ15
Number of Individuals Covered184
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $5,390
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,356
Amount paid for insurance broker fees1034
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 3
Insurance contract or identification number10946
Number of Individuals Covered202
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $10,675
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $194,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,675
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP68849 P68850
Policy instance 1
Insurance contract or identification numberP68849 P68850
Number of Individuals Covered459
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $91,749
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,594,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $89,849
Amount paid for insurance broker fees1900
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AQ15
Policy instance 2
Insurance contract or identification numberGLUG0AQ15
Number of Individuals Covered209
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $7,271
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $43,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,541
Amount paid for insurance broker fees730
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 3
Insurance contract or identification number10946
Number of Individuals Covered204
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $10,879
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $164,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,879
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract numberF3IW
Policy instance 4
Insurance contract or identification numberF3IW
Number of Individuals Covered93
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $121
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $121
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AQ15
Policy instance 5
Insurance contract or identification numberGLTD0AQ15
Number of Individuals Covered191
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $4,857
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,335
Amount paid for insurance broker fees522
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number000064047580
Policy instance 6
Insurance contract or identification number000064047580
Number of Individuals Covered190
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $890
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $890
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES INC
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018010
Policy instance 2
Insurance contract or identification numberF018010
Number of Individuals Covered203
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $10,994
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $71,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,684
Amount paid for insurance broker fees310
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW CONSULTING SERVICES INC
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 3
Insurance contract or identification number10946
Number of Individuals Covered199
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $11,104
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $185,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,104
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number238423
Policy instance 4
Insurance contract or identification number238423
Number of Individuals Covered79
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $1,113
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,113
Insurance broker organization code?3
Insurance broker nameMESIROW FINANCIAL
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP68849/50
Policy instance 1
Insurance contract or identification numberP68849/50
Number of Individuals Covered441
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $86,001
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,373,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $83,006
Amount paid for insurance broker fees2995
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018010
Policy instance 4
Insurance contract or identification numberF018010
Number of Individuals Covered187
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $13,984
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $67,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,069
Amount paid for insurance broker fees3915
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number238423
Policy instance 3
Insurance contract or identification number238423
Number of Individuals Covered60
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $883
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $883
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 2
Insurance contract or identification number10946
Number of Individuals Covered182
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $11,168
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $147,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,626
Amount paid for insurance broker fees1542
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP68849/50
Policy instance 1
Insurance contract or identification numberP68849/50
Number of Individuals Covered424
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $89,586
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,171,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $86,751
Amount paid for insurance broker fees2835
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP68849/P68850
Policy instance 1
Insurance contract or identification numberP68849/P68850
Number of Individuals Covered390
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $89,098
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,917,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10946
Policy instance 2
Insurance contract or identification number10946
Number of Individuals Covered175
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $9,283
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $154,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ADBI
Policy instance 5
Insurance contract or identification numberGLTD0ADBI
Number of Individuals Covered165
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ADBI
Policy instance 4
Insurance contract or identification numberG000ADBI
Number of Individuals Covered180
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $38,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number238423
Policy instance 3
Insurance contract or identification number238423
Number of Individuals Covered57
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $885
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ADBI
Policy instance 5
Insurance contract or identification numberGLTD0ADBI
Number of Individuals Covered163
Insurance policy start date2009-07-01
Insurance policy end date2010-06-30
Total amount of commissions paid to insurance brokerUSD $3,696
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,696
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number238423
Policy instance 3
Insurance contract or identification number238423
Number of Individuals Covered58
Insurance policy start date2009-07-01
Insurance policy end date2010-06-30
Total amount of commissions paid to insurance brokerUSD $853
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $853
Insurance broker organization code?3
Insurance broker nameMESIROW FINANCIAL
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05559624
Policy instance 2
Insurance contract or identification numberKM05559624
Number of Individuals Covered585
Insurance policy start date2009-07-01
Insurance policy end date2010-06-30
Total amount of commissions paid to insurance brokerUSD $11,819
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $135,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,864
Amount paid for insurance broker fees2955
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP68849,P68850
Policy instance 1
Insurance contract or identification numberP68849,P68850
Number of Individuals Covered370
Insurance policy start date2009-07-01
Insurance policy end date2010-06-30
Total amount of commissions paid to insurance brokerUSD $86,248
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,843,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $83,032
Amount paid for insurance broker fees3216
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameMESIROW FINANCIAL
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ADBI
Policy instance 4
Insurance contract or identification numberGLUG0ADBI
Number of Individuals Covered174
Insurance policy start date2009-07-01
Insurance policy end date2010-06-30
Total amount of commissions paid to insurance brokerUSD $6,696
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $36,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,696
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICE

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