HYDROMAX USA LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan HYDROMAX USA LLC PREMIUM ONLY PLAN
| Measure | Date | Value |
|---|
| 2022: HYDROMAX USA LLC PREMIUM ONLY PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-12-01 | 614 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-12-01 | 470 |
| Number of retired or separated participants receiving benefits | 2022-12-01 | 16 |
| Number of other retired or separated participants entitled to future benefits | 2022-12-01 | 0 |
| Total of all active and inactive participants | 2022-12-01 | 486 |
| Number of employers contributing to the scheme | 2022-12-01 | 0 |
| 2021: HYDROMAX USA LLC PREMIUM ONLY PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-01 | 492 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-01 | 599 |
| Number of retired or separated participants receiving benefits | 2021-12-01 | 15 |
| Number of other retired or separated participants entitled to future benefits | 2021-12-01 | 0 |
| Total of all active and inactive participants | 2021-12-01 | 614 |
| Number of employers contributing to the scheme | 2021-12-01 | 0 |
| 2020: HYDROMAX USA LLC PREMIUM ONLY PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 379 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 488 |
| Number of retired or separated participants receiving benefits | 2020-12-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-01 | 0 |
| Total of all active and inactive participants | 2020-12-01 | 492 |
| 2019: HYDROMAX USA LLC PREMIUM ONLY PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 528 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 379 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 379 |
| 2018: HYDROMAX USA LLC PREMIUM ONLY PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 517 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 528 |
| Number of retired or separated participants receiving benefits | 2018-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-01 | 0 |
| Total of all active and inactive participants | 2018-12-01 | 528 |
| 2017: HYDROMAX USA LLC PREMIUM ONLY PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 446 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 517 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 0 |
| Total of all active and inactive participants | 2017-12-01 | 517 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-12-01 | 0 |
| 2016: HYDROMAX USA LLC PREMIUM ONLY PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 331 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 446 |
| Number of retired or separated participants receiving benefits | 2016-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-01 | 0 |
| Total of all active and inactive participants | 2016-12-01 | 446 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2016-12-01 | 0 |
| 2015: HYDROMAX USA LLC PREMIUM ONLY PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 99 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 331 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-12-01 | 0 |
| Total of all active and inactive participants | 2015-12-01 | 331 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-12-01 | 0 |
| 2022: HYDROMAX USA LLC PREMIUM ONLY PLAN 2022 form 5500 responses |
|---|
| 2022-12-01 | Type of plan entity | Single employer plan |
| 2022-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2022-12-01 | Plan funding arrangement – Insurance | Yes |
| 2022-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: HYDROMAX USA LLC PREMIUM ONLY PLAN 2021 form 5500 responses |
|---|
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Plan funding arrangement – Insurance | Yes |
| 2021-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: HYDROMAX USA LLC PREMIUM ONLY PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: HYDROMAX USA LLC PREMIUM ONLY PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Submission has been amended | No |
| 2019-12-01 | This submission is the final filing | No |
| 2019-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-12-01 | Plan is a collectively bargained plan | No |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: HYDROMAX USA LLC PREMIUM ONLY PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Submission has been amended | No |
| 2018-12-01 | This submission is the final filing | No |
| 2018-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-12-01 | Plan is a collectively bargained plan | No |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: HYDROMAX USA LLC PREMIUM ONLY PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Submission has been amended | No |
| 2017-12-01 | This submission is the final filing | No |
| 2017-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-12-01 | Plan is a collectively bargained plan | No |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: HYDROMAX USA LLC PREMIUM ONLY PLAN 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Submission has been amended | No |
| 2016-12-01 | This submission is the final filing | No |
| 2016-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-12-01 | Plan is a collectively bargained plan | No |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: HYDROMAX USA LLC PREMIUM ONLY PLAN 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | First time form 5500 has been submitted | Yes |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | IN2375 |
| Policy instance | 3 |
| Insurance contract or identification number | IN2375 | | Number of Individuals Covered | 483 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,050 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $171,165 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,050 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10344951001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10344951001 | | Number of Individuals Covered | 424 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 948241 |
| Policy instance | 2 |
| Insurance contract or identification number | 948241 | | Number of Individuals Covered | 470 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,342 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $24,380 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,409 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
| Policy contract number | 10171 |
| Policy instance | 4 |
| Insurance contract or identification number | 10171 | | Number of Individuals Covered | 485 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $743 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $743 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 948241 |
| Policy instance | 2 |
| Insurance contract or identification number | 948241 | | Number of Individuals Covered | 599 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $50,675 | | Total amount of fees paid to insurance company | USD $13,382 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $247,732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,685 | | Amount paid for insurance broker fees | 13382 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | IN2375 |
| Policy instance | 3 |
| Insurance contract or identification number | IN2375 | | Number of Individuals Covered | 486 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $63,596 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,224,140 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $63,596 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
| Policy contract number | 10171 |
| Policy instance | 4 |
| Insurance contract or identification number | 10171 | | Number of Individuals Covered | 492 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $8,138 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,138 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10344951001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10344951001 | | Number of Individuals Covered | 431 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $1,752 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,031 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,752 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BSRD |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0BSRD | | Number of Individuals Covered | 124 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $4,604 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $31,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,597 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BSRD |
| Policy instance | 6 |
| Insurance contract or identification number | GUC 0BSRD | | Number of Individuals Covered | 230 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $3,882 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,638 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,676 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLLV0BSRD |
| Policy instance | 5 |
| Insurance contract or identification number | GLLV0BSRD | | Number of Individuals Covered | 262 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $1,984 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,303 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BSRD |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BSRD | | Number of Individuals Covered | 488 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $2,095 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,171 | | Insurance broker organization code? | 3 |
|
| HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 ) |
| Policy contract number | 507430751030 |
| Policy instance | 3 |
| Insurance contract or identification number | 507430751030 | | Number of Individuals Covered | 428 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $7,299 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,284 | | Insurance broker organization code? | 3 |
|
| HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 ) |
| Policy contract number | 1125191104HY |
| Policy instance | 2 |
| Insurance contract or identification number | 1125191104HY | | Number of Individuals Covered | 66 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $982 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,816 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $535 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | IN2375 |
| Policy instance | 1 |
| Insurance contract or identification number | IN2375 | | Number of Individuals Covered | 519 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $58,350 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,858,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,370 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | IN2375 |
| Policy instance | 1 |
| Insurance contract or identification number | IN2375 | | Number of Individuals Covered | 397 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $49,114 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,453,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,114 | | Insurance broker organization code? | 3 |
|
| HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 ) |
| Policy contract number | 507430751030 |
| Policy instance | 2 |
| Insurance contract or identification number | 507430751030 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $6,001 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $85,725 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,001 | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010258900 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010258900 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,702 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,302 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,702 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30079238 |
| Policy instance | 4 |
| Insurance contract or identification number | 30079238 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,027 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,129 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,027 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 909706 |
| Policy instance | 1 |
| Insurance contract or identification number | 909706 | | Number of Individuals Covered | 528 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $58,760 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,535,903 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,760 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 909706 |
| Policy instance | 1 |
| Insurance contract or identification number | 909706 | | Number of Individuals Covered | 517 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $52,229 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,366,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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