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NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 401k Plan overview

Plan NameNICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT
Plan identification number 520

NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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

401k Sponsoring company profile

NICHOLAS H NOYES MEMORIAL HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name:NICHOLAS H NOYES MEMORIAL HOSPITAL
Employer identification number (EIN):160743979
NAIC Classification:622000
NAIC Description: Hospitals

Additional information about NICHOLAS H NOYES MEMORIAL HOSPITAL

Jurisdiction of Incorporation: New York Department of State
Incorporation Date: 1920-10-27
Company Identification Number: 16052
Legal Registered Office Address: 111 CLARA BARTON STREET
Livingston
DANSVILLE
United States of America (USA)
14437

More information about NICHOLAS H NOYES MEMORIAL HOSPITAL

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5202022-01-01CASSANDRA DAVIS2023-06-26
5202021-01-01
5202020-01-01
5202019-01-01
5202018-01-01CASSANDRA WEITZEL
5202017-01-01AMY SKINNER
5202016-01-01GAIL WING GAIL WING2017-06-28
5202016-01-01AMY SKINNER AMY SKINNER2018-06-29
5202015-01-01GAIL WING
5202014-01-01GAIL WING
5202013-01-01GAIL WING
5202012-01-01JEANINE WILDER
5202011-01-01JEANINE WILDER JEANINE WILDER2012-10-11
5202010-01-01JEANINE WILDER
5202009-01-01 DENISE MORLEY2010-07-30
5202009-01-01DENISE MORLEY
5202009-01-01DENISE MORLEY
5202009-01-01DENISE MORLEY

Plan Statistics for NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT

401k plan membership statisitcs for NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT

Measure Date Value
2022: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2022 401k membership
Total participants, beginning-of-year2022-01-01358
Total number of active participants reported on line 7a of the Form 55002022-01-01386
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01386
2021: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2021 401k membership
Total participants, beginning-of-year2021-01-01389
Total number of active participants reported on line 7a of the Form 55002021-01-01374
Total of all active and inactive participants2021-01-01374
2020: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2020 401k membership
Total participants, beginning-of-year2020-01-01385
Total number of active participants reported on line 7a of the Form 55002020-01-01389
Total of all active and inactive participants2020-01-01389
2019: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2019 401k membership
Total participants, beginning-of-year2019-01-01387
Total number of active participants reported on line 7a of the Form 55002019-01-01385
Total of all active and inactive participants2019-01-01385
2018: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2018 401k membership
Total participants, beginning-of-year2018-01-01367
Total of all active and inactive participants2018-01-010
2017: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2017 401k membership
Total participants, beginning-of-year2017-01-01365
Total number of active participants reported on line 7a of the Form 55002017-01-01367
Total of all active and inactive participants2017-01-01367
2016: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2016 401k membership
Total participants, beginning-of-year2016-01-01365
Total number of active participants reported on line 7a of the Form 55002016-01-01367
Total of all active and inactive participants2016-01-01367
2015: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2015 401k membership
Total participants, beginning-of-year2015-01-01360
Total number of active participants reported on line 7a of the Form 55002015-01-01365
Total of all active and inactive participants2015-01-01365
2014: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2014 401k membership
Total participants, beginning-of-year2014-01-01357
Total number of active participants reported on line 7a of the Form 55002014-01-01360
Total of all active and inactive participants2014-01-01360
2013: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2013 401k membership
Total participants, beginning-of-year2013-01-01312
Total number of active participants reported on line 7a of the Form 55002013-01-01357
Total of all active and inactive participants2013-01-01357
2012: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2012 401k membership
Total participants, beginning-of-year2012-01-01385
Total number of active participants reported on line 7a of the Form 55002012-01-01312
Number of retired or separated participants receiving benefits2012-01-010
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01312
2011: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2011 401k membership
Total participants, beginning-of-year2011-01-01300
Total number of active participants reported on line 7a of the Form 55002011-01-01385
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01385
2010: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2010 401k membership
Total participants, beginning-of-year2010-01-01293
Total number of active participants reported on line 7a of the Form 55002010-01-01300
Number of retired or separated participants receiving benefits2010-01-010
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-01300
2009: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 2009 401k membership
Total participants, beginning-of-year2009-01-01303
Total number of active participants reported on line 7a of the Form 55002009-01-01293
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01293

Form 5500 Responses for NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT

2022: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: NICHOLAS H NOYES MEMORIAL HOSPITAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00493079
Policy instance 4
Insurance contract or identification number00493079
Number of Individuals Covered230
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,600
Total amount of fees paid to insurance companyUSD $1,370
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $61,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,605
Insurance broker organization code?3
Amount paid for insurance broker fees1300
Additional information about fees paid to insurance brokerFEES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberGMC 0AKYX
Policy instance 3
Insurance contract or identification numberGMC 0AKYX
Number of Individuals Covered122
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,317
Total amount of fees paid to insurance companyUSD $5,382
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $62,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,763
Amount paid for insurance broker fees3588
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number414130
Policy instance 2
Insurance contract or identification number414130
Number of Individuals Covered418
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $98,704
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,958,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $55,162
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017710-00
Policy instance 1
Insurance contract or identification number01-017710-00
Number of Individuals Covered386
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,970
Total amount of fees paid to insurance companyUSD $4,520
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $76,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,378
Amount paid for insurance broker fees4211
Additional information about fees paid to insurance brokerNY GROUP VOLUME BONUS
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017710-00
Policy instance 1
Insurance contract or identification number01-017710-00
Number of Individuals Covered374
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,500
Total amount of fees paid to insurance companyUSD $701
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $51,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,500
Amount paid for insurance broker fees701
Additional information about fees paid to insurance brokerGROUP VOLUME BONUS
Insurance broker organization code?3
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number414130
Policy instance 2
Insurance contract or identification number414130
Number of Individuals Covered473
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $656
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,181,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $656
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AKYX
Policy instance 3
Insurance contract or identification numberG000AKYX
Number of Individuals Covered130
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $4,506
Total amount of fees paid to insurance companyUSD $3,190
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $65,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,506
Amount paid for insurance broker fees1718
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00493079
Policy instance 4
Insurance contract or identification number00493079
Number of Individuals Covered239
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,429
Total amount of fees paid to insurance companyUSD $1,575
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,429
Amount paid for insurance broker fees1575
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017710-00
Policy instance 1
Insurance contract or identification number01-017710-00
Number of Individuals Covered389
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $8,134
Total amount of fees paid to insurance companyUSD $2,071
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE AND DEPENDENT LIFE
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 $68,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,134
Amount paid for insurance broker fees2071
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number414130
Policy instance 2
Insurance contract or identification number414130
Number of Individuals Covered529
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $106,925
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,037,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $106,925
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberGMC 0AKYX
Policy instance 3
Insurance contract or identification numberGMC 0AKYX
Number of Individuals Covered110
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,074
Total amount of fees paid to insurance companyUSD $4,425
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $53,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,074
Amount paid for insurance broker fees2655
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00493079
Policy instance 4
Insurance contract or identification number00493079
Number of Individuals Covered269
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,226
Total amount of fees paid to insurance companyUSD $3,280
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $52,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,226
Amount paid for insurance broker fees3280
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00493079
Policy instance 4
Insurance contract or identification number00493079
Number of Individuals Covered274
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,666
Total amount of fees paid to insurance companyUSD $2,786
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $59,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,666
Amount paid for insurance broker fees2786
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberGMC0AKYX
Policy instance 3
Insurance contract or identification numberGMC0AKYX
Number of Individuals Covered112
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,134
Total amount of fees paid to insurance companyUSD $1,720
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $54,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,134
Amount paid for insurance broker fees1720
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number414130
Policy instance 2
Insurance contract or identification number414130
Number of Individuals Covered533
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $99,993
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,789,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $99,993
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017710-00
Policy instance 1
Insurance contract or identification number01-017710-00
Number of Individuals Covered385
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $8,011
Total amount of fees paid to insurance companyUSD $3,658
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE AND DEPENDENT LIFE
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 $66,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,011
Amount paid for insurance broker fees3658
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberFLY960256
Policy instance 1
Insurance contract or identification numberFLY960256
Number of Individuals Covered367
Insurance policy start date2018-01-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $598
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE AND DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $598
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017710-00
Policy instance 2
Insurance contract or identification number01-017710-00
Number of Individuals Covered387
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $7,220
Total amount of fees paid to insurance companyUSD $327
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $56,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,220
Insurance broker organization code?3
Amount paid for insurance broker fees327
Additional information about fees paid to insurance brokerGROUP VOLUME BONUS
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number414130
Policy instance 3
Insurance contract or identification number414130
Number of Individuals Covered535
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $101,942
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,848,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $101,942
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberGMC0AKYX
Policy instance 4
Insurance contract or identification numberGMC0AKYX
Number of Individuals Covered116
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $4,007
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $53,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,007
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00493079
Policy instance 5
Insurance contract or identification number00493079
Number of Individuals Covered269
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,807
Total amount of fees paid to insurance companyUSD $3,237
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $56,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,759
Amount paid for insurance broker fees3237
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00493079
Policy instance 4
Insurance contract or identification number00493079
Number of Individuals Covered263
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,169
Total amount of fees paid to insurance companyUSD $2,731
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $46,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,110
Amount paid for insurance broker fees2731
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberGMC0AKYX
Policy instance 3
Insurance contract or identification numberGMC0AKYX
Number of Individuals Covered124
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,255
Total amount of fees paid to insurance companyUSD $3,556
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $57,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,255
Amount paid for insurance broker fees1915
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number414130
Policy instance 2
Insurance contract or identification number414130
Number of Individuals Covered564
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $92,210
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,624,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $92,210
Insurance broker organization code?3
Insurance broker nameROBERT G. RELPH AGENCY, INC.
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberFLY960256
Policy instance 1
Insurance contract or identification numberFLY960256
Number of Individuals Covered367
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,647
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE AND DEPENDENT LIFE
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 $72,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,647
Insurance broker organization code?3
Insurance broker nameROBERT G. RELPH AGENCY, INC.
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberFLY960256
Policy instance 1
Insurance contract or identification numberFLY960256
Number of Individuals Covered365
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,323
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE AND DEPENDENT LIFE
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 $66,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,323
Insurance broker organization code?3
Insurance broker nameROBERT G. RELPH AGENCY, INC.
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number414130
Policy instance 2
Insurance contract or identification number414130
Number of Individuals Covered596
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $83,223
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,227,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $83,223
Insurance broker organization code?3
Insurance broker nameROBERT G. RELPH AGENCY, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberGMC0AKYX
Policy instance 3
Insurance contract or identification numberGMC0AKYX
Number of Individuals Covered120
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $4,044
Total amount of fees paid to insurance companyUSD $967
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare 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 $50,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,044
Amount paid for insurance broker fees967
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameROBERT G. RELPH AGENCY, INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00493079
Policy instance 4
Insurance contract or identification number00493079
Number of Individuals Covered251
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,261
Total amount of fees paid to insurance companyUSD $2,391
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 $39,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,727
Amount paid for insurance broker fees2391
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00493079
Policy instance 2
Insurance contract or identification number00493079
Number of Individuals Covered245
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,204
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $34,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,354
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AKYX
Policy instance 4
Insurance contract or identification numberG000AKYX
Number of Individuals Covered127
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,505
Total amount of fees paid to insurance companyUSD $1,170
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare 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 $39,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,505
Amount paid for insurance broker fees1170
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameROBERT G. RELPH AGENCY, INC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberFLY960256
Policy instance 3
Insurance contract or identification numberFLY960256
Number of Individuals Covered360
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,043
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $60,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,043
Insurance broker organization code?3
Insurance broker nameROBERT G. RELPH AGENCY, INC.
MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 )
Policy contract number414130
Policy instance 1
Insurance contract or identification number414130
Number of Individuals Covered625
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $72,763
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,956,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $72,763
Insurance broker organization code?3
Insurance broker nameROBERT G. RELPH AGENCY, INC.
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberFLY960256
Policy instance 2
Insurance contract or identification numberFLY960256
Number of Individuals Covered357
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $2,709
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $54,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,709
Insurance broker organization code?3
Insurance broker nameROBERT G RELPH AGENCY INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AKYX
Policy instance 1
Insurance contract or identification numberG000AKYX
Number of Individuals Covered115
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,285
Total amount of fees paid to insurance companyUSD $776
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare 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 $36,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,285
Amount paid for insurance broker fees776
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameROBERT G RELPH AGENCY INC
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number32694
Policy instance 3
Insurance contract or identification number32694
Number of Individuals Covered259
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $61,597
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $61,597
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberFLY960256
Policy instance 2
Insurance contract or identification numberFLY960256
Number of Individuals Covered312
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $2,548
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $50,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,548
Insurance broker organization code?3
Insurance broker nameROBERT G RELPH AGENCY, INC.
HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )
Policy contract number871892G
Policy instance 3
Insurance contract or identification number871892G
Number of Individuals Covered147
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $731
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $731
Insurance broker organization code?3
Insurance broker nameROBERT G RELPH AGENCY, INC.
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number8002
Policy instance 1
Insurance contract or identification number8002
Number of Individuals Covered6
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10102918
Policy instance 4
Insurance contract or identification number10102918
Number of Individuals Covered133
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $5,259
Total amount of fees paid to insurance companyUSD $3,236
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare 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 $35,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberFNYH893303
Policy instance 3
Insurance contract or identification numberFNYH893303
Number of Individuals Covered385
Insurance policy start date2011-01-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $2,772
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $50,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number8002-003
Policy instance 1
Insurance contract or identification number8002-003
Number of Individuals Covered715
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $76,213
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10102918
Policy instance 3
Insurance contract or identification number10102918
Number of Individuals Covered135
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $5,846
Total amount of fees paid to insurance companyUSD $3,719
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare 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 $38,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )
Policy contract number8002-003
Policy instance 1
Insurance contract or identification number8002-003
Number of Individuals Covered301
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $102,679
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberFNYH893303
Policy instance 2
Insurance contract or identification numberFNYH893303
Number of Individuals Covered400
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $4,916
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $62,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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