ADAMS THERMAL SYSTEMS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN
401k plan membership statisitcs for ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN
| Measure | Date | Value |
|---|
| 2022: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 246 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 294 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 294 |
| 2021: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 178 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 216 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 216 |
| 2020: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 233 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 174 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 174 |
| 2019: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 324 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 242 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 242 |
| 2018: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 314 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 305 |
| Total of all active and inactive participants | 2018-01-01 | 305 |
| 2017: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 219 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 305 |
| Total of all active and inactive participants | 2017-01-01 | 305 |
| 2016: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 219 |
| Total of all active and inactive participants | 2016-01-01 | 219 |
| 2015: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 390 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 265 |
| Total of all active and inactive participants | 2015-01-01 | 265 |
| 2014: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 674 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 397 |
| Total of all active and inactive participants | 2014-01-01 | 397 |
| 2013: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 1,194 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 727 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 1 |
| Total of all active and inactive participants | 2013-01-01 | 728 |
| 2012: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 662 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 1,194 |
| Total of all active and inactive participants | 2012-01-01 | 1,194 |
| 2011: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 451 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 662 |
| Total of all active and inactive participants | 2011-01-01 | 662 |
| 2009: ADAMS THERMAL SYSTEMS, INC. EMPLOYEE GROUP LIFE INSURANCE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 104 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 122 |
| Total of all active and inactive participants | 2009-01-01 | 122 |
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | 4917167 |
| Policy instance | 5 |
| Insurance contract or identification number | 4917167 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,827 | | Total amount of fees paid to insurance company | USD $686 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,723 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,459 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 259 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK967981 |
| Policy instance | 4 |
| Insurance contract or identification number | OK967981 | | Number of Individuals Covered | 324 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $67 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,396 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 67 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX966452 |
| Policy instance | 3 |
| Insurance contract or identification number | FLX966452 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $587 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,169 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 587 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 963612 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 963612 | | Number of Individuals Covered | 280 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $376 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 376 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 1 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $223 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,465 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $156 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 1 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $231 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,616 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $162 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 963612 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 963612 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,709 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX966452 |
| Policy instance | 3 |
| Insurance contract or identification number | FLX966452 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK967981 |
| Policy instance | 4 |
| Insurance contract or identification number | OK967981 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $4,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | 4917167 |
| Policy instance | 5 |
| Insurance contract or identification number | 4917167 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $5,969 | | Total amount of fees paid to insurance company | USD $1,410 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,874 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,851 | | Amount paid for insurance broker fees | 1049 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 1 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $275 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $192 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 963612 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 963612 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX966452 |
| Policy instance | 3 |
| Insurance contract or identification number | FLX966452 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK967981 |
| Policy instance | 4 |
| Insurance contract or identification number | OK967981 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $2,657 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | 4917167 |
| Policy instance | 5 |
| Insurance contract or identification number | 4917167 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $13,579 | | Total amount of fees paid to insurance company | USD $3,345 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,300 | | Amount paid for insurance broker fees | 2200 | | Additional information about fees paid to insurance broker | INSURANCE FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 963612 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 963612 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 1 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $359 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,025 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $251 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX966452 |
| Policy instance | 3 |
| Insurance contract or identification number | FLX966452 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK967981 |
| Policy instance | 4 |
| Insurance contract or identification number | OK967981 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,149 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4917167 |
| Policy instance | 5 |
| Insurance contract or identification number | E4917167 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $17,920 | | Total amount of fees paid to insurance company | USD $6,365 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,599 | | Amount paid for insurance broker fees | 635 | | Additional information about fees paid to insurance broker | INSURANCE FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK967981 |
| Policy instance | 6 |
| Insurance contract or identification number | OK967981 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $4,169 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX966452 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX966452 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,885 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 751305 |
| Policy instance | 4 |
| Insurance contract or identification number | LK 751305 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,521 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 963612 |
| Policy instance | 3 |
| Insurance contract or identification number | LK 963612 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0306696 |
| Policy instance | 2 |
| Insurance contract or identification number | R0306696 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $144 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $4,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $112 | | Insurance broker organization code? | 3 | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 1 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $689 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $21,530 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $496 | | Insurance broker organization code? | 3 | | Insurance broker name | DWIGHT L. PIERCE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 963612 |
| Policy instance | 3 |
| Insurance contract or identification number | LK 963612 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,050 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,341 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 942 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 751305 |
| Policy instance | 4 |
| Insurance contract or identification number | LK 751305 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,160 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1031 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX966452 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX966452 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $2,595 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,115 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2595 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 1 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,310 | | Total amount of fees paid to insurance company | USD $749 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $40,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,521 | | Amount paid for insurance broker fees | 749 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HOWALT MCDOWELL INS, A MARSH & MCLE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK967981 |
| Policy instance | 6 |
| Insurance contract or identification number | OK967981 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $225 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,189 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 225 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0306696 |
| Policy instance | 2 |
| Insurance contract or identification number | R0306696 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $510 | | Total amount of fees paid to insurance company | USD $11 | | Other welfare benefits provided | GCIEE | | Welfare Benefit Premiums Paid to Carrier | USD $7,294 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $235 | | Amount paid for insurance broker fees | 6 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HOWALT MCDOWELL INS, A MARSH & MCLE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 751305 |
| Policy instance | 4 |
| Insurance contract or identification number | LK 751305 | | Number of Individuals Covered | 397 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,465 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,942 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,465 | | Insurance broker organization code? | 3 | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 963612 |
| Policy instance | 3 |
| Insurance contract or identification number | LK 963612 | | Number of Individuals Covered | 397 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,356 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,518 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,356 | | Insurance broker organization code? | 3 | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0306696 |
| Policy instance | 2 |
| Insurance contract or identification number | R0306696 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,045 | | Total amount of fees paid to insurance company | USD $277 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | GCIEE | | Welfare Benefit Premiums Paid to Carrier | USD $13,629 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,372 | | Amount paid for insurance broker fees | 176 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
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| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 1 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 328 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $35,779 | | Total amount of fees paid to insurance company | USD $2,467 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $65,742 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,083 | | Amount paid for insurance broker fees | 2509 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DWIGHT L. PIERCE |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0306696 |
| Policy instance | 4 |
| Insurance contract or identification number | R0306696 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,703 | | Total amount of fees paid to insurance company | USD $376 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | GCIEE | | Welfare Benefit Premiums Paid to Carrier | USD $15,847 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,890 | | Amount paid for insurance broker fees | 372 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 905214 |
| Policy instance | 1 |
| Insurance contract or identification number | 905214 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $13,531 | | Total amount of fees paid to insurance company | USD $1,579 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $90,204 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,531 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1579 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 905213 |
| Policy instance | 2 |
| Insurance contract or identification number | 905213 | | Number of Individuals Covered | 672 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,936 | | Total amount of fees paid to insurance company | USD $1,472 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $67,610 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,936 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1472 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 751305 |
| Policy instance | 6 |
| Insurance contract or identification number | LK 751305 | | Number of Individuals Covered | 727 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,815 | | Total amount of fees paid to insurance company | USD $2,372 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $86,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,815 | | Amount paid for insurance broker fees | 2372 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 963612 |
| Policy instance | 5 |
| Insurance contract or identification number | LK 963612 | | Number of Individuals Covered | 727 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,883 | | Total amount of fees paid to insurance company | USD $3,154 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $88,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,883 | | Amount paid for insurance broker fees | 3154 | | Additional information about fees paid to insurance broker | BROKERS FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
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| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 3 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $11,562 | | Total amount of fees paid to insurance company | USD $2,225 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $37,190 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,080 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2225 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | DWIGHT L. PIERCE |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 905213 |
| Policy instance | 2 |
| Insurance contract or identification number | 905213 | | Number of Individuals Covered | 1127 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $11,436 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $168,144 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,436 | | Insurance broker organization code? | 3 | | Insurance broker name | KGO INC |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 3 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $720 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,941 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $720 | | Insurance broker organization code? | 3 | | Insurance broker name | HOLMES MURPHY & ASSOCIATES INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 905214 |
| Policy instance | 1 |
| Insurance contract or identification number | 905214 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $12,408 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $82,722 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,408 | | Insurance broker organization code? | 3 | | Insurance broker name | KGO INC |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008211937 |
| Policy instance | 3 |
| Insurance contract or identification number | 008211937 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $138 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $21,473 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 905213 |
| Policy instance | 2 |
| Insurance contract or identification number | 905213 | | Number of Individuals Covered | 662 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $10,788 | | Total amount of fees paid to insurance company | USD $1,045 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $139,295 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 905214 |
| Policy instance | 1 |
| Insurance contract or identification number | 905214 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $12,143 | | Total amount of fees paid to insurance company | USD $607 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $80,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 905213 |
| Policy instance | 2 |
| Insurance contract or identification number | 905213 | | Number of Individuals Covered | 436 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $9,169 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $105,384 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,169 | | Insurance broker organization code? | 3 | | Insurance broker name | KGO INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 905214 |
| Policy instance | 1 |
| Insurance contract or identification number | 905214 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $8,865 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $59,096 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,865 | | Insurance broker organization code? | 3 | | Insurance broker name | KGO INC |
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