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GROUP BENEFIT PLAN 401k Plan overview

Plan NameGROUP BENEFIT PLAN
Plan identification number 501

GROUP BENEFIT PLAN Benefits

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

401k Sponsoring company profile

PRESTOLITE ELECTRIC, LLC has sponsored the creation of one or more 401k plans.

Company Name:PRESTOLITE ELECTRIC, LLC
Employer identification number (EIN):201112687
NAIC Classification:335900

Additional information about PRESTOLITE ELECTRIC, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 3759752

More information about PRESTOLITE ELECTRIC, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GROUP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01
5012017-01-01DEBRA BEVANS
5012016-01-01DONNA LILLY
5012015-01-01DONNA LILLY
5012014-01-01DONNA LILLY
5012013-01-01DENNIS CHELMINSKI DENNIS CHELMINSKI2015-02-27

Plan Statistics for GROUP BENEFIT PLAN

401k plan membership statisitcs for GROUP BENEFIT PLAN

Measure Date Value
2022: GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01344
Total number of active participants reported on line 7a of the Form 55002022-01-01341
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 participants2022-01-01341
2021: GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01436
Total number of active participants reported on line 7a of the Form 55002021-01-01344
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01344
2020: GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01463
Total number of active participants reported on line 7a of the Form 55002020-01-01436
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01436
2019: GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01466
Total number of active participants reported on line 7a of the Form 55002019-01-01463
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01463
2018: GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01508
Total number of active participants reported on line 7a of the Form 55002018-01-01466
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01466
2017: GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01548
Total number of active participants reported on line 7a of the Form 55002017-01-01508
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01508
2016: GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01634
Total number of active participants reported on line 7a of the Form 55002016-01-01548
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01548
2015: GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01717
Total number of active participants reported on line 7a of the Form 55002015-01-01634
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01634
2014: GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01893
Total number of active participants reported on line 7a of the Form 55002014-01-01717
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01717
2013: GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01939
Total number of active participants reported on line 7a of the Form 55002013-01-01893
Total of all active and inactive participants2013-01-01893

Form 5500 Responses for GROUP BENEFIT PLAN

2022: GROUP BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: GROUP BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: GROUP BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: GROUP BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: GROUP BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: GROUP BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: GROUP BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: GROUP BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: GROUP BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: GROUP BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedYes
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 3
Insurance contract or identification number30025262
Number of Individuals Covered85
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $366
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $366
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )
Policy contract number00401365
Policy instance 1
Insurance contract or identification number00401365
Number of Individuals Covered293
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of fees paid to insurance companyUSD $489,020
Other welfare benefits providedPOS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees489020
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 965553
Policy instance 2
Insurance contract or identification numberOK 965553
Insurance policy start date2022-04-01
Insurance policy end date2022-04-01
Total amount of fees paid to insurance companyUSD $104
Other welfare benefits providedACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees104
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number00400269242
Policy instance 12
Insurance contract or identification number00400269242
Number of Individuals Covered86
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $790
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $790
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYD074864
Policy instance 5
Insurance contract or identification numberNYD074864
Insurance policy start date2022-04-01
Insurance policy end date2022-04-01
Total amount of fees paid to insurance companyUSD $1,891
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1891
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963926
Policy instance 4
Insurance contract or identification numberFLX963926
Insurance policy start date2022-04-01
Insurance policy end date2022-04-01
Total amount of commissions paid to insurance brokerUSD $1,723
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,723
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0001971
Policy instance 6
Insurance contract or identification number0001971
Number of Individuals Covered341
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $3,688
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,688
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960824
Policy instance 7
Insurance contract or identification numberVDT960824
Insurance policy start date2022-04-01
Insurance policy end date2022-04-01
Total amount of fees paid to insurance companyUSD $476
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees476
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number000010269223
Policy instance 8
Insurance contract or identification number000010269223
Number of Individuals Covered230
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $2,593
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,593
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number000010269224
Policy instance 9
Insurance contract or identification number000010269224
Number of Individuals Covered107
Insurance policy start date2022-04-01
Insurance policy end date2023-06-21
Total amount of commissions paid to insurance brokerUSD $3,085
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,085
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number00400269225
Policy instance 11
Insurance contract or identification number00400269225
Number of Individuals Covered40
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $5,940
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $39,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,940
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number000403008096
Policy instance 10
Insurance contract or identification number000403008096
Number of Individuals Covered42
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $424
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $424
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )
Policy contract number00401365
Policy instance 1
Insurance contract or identification number00401365
Number of Individuals Covered305
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of fees paid to insurance companyUSD $2,519
Other welfare benefits providedPOS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees2519
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 750929
Policy instance 4
Insurance contract or identification numberLK 750929
Insurance policy start date2021-04-01
Insurance policy end date2022-04-01
Total amount of commissions paid to insurance brokerUSD $96
Total amount of fees paid to insurance companyUSD $64
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $96
Amount paid for insurance broker fees64
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYD074864
Policy instance 6
Insurance contract or identification numberNYD074864
Number of Individuals Covered178
Insurance policy start date2021-04-01
Insurance policy end date2021-04-01
Total amount of commissions paid to insurance brokerUSD $8,971
Total amount of fees paid to insurance companyUSD $1,479
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $89,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,971
Amount paid for insurance broker fees1479
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960824
Policy instance 8
Insurance contract or identification numberVDT960824
Number of Individuals Covered60
Insurance policy start date2021-04-01
Insurance policy end date2022-04-01
Total amount of commissions paid to insurance brokerUSD $3,836
Total amount of fees paid to insurance companyUSD $485
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,193
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,836
Amount paid for insurance broker fees485
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 965553
Policy instance 2
Insurance contract or identification numberOK 965553
Number of Individuals Covered126
Insurance policy start date2021-04-01
Insurance policy end date2022-04-01
Total amount of commissions paid to insurance brokerUSD $580
Total amount of fees paid to insurance companyUSD $123
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $5,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $580
Amount paid for insurance broker fees123
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0001971
Policy instance 7
Insurance contract or identification number0001971
Number of Individuals Covered344
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $2,867
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,867
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 3
Insurance contract or identification number30025262
Number of Individuals Covered90
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $917
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $917
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963926
Policy instance 5
Insurance contract or identification numberFLX963926
Number of Individuals Covered34
Insurance policy start date2021-04-01
Insurance policy end date2022-04-01
Total amount of commissions paid to insurance brokerUSD $8,988
Total amount of fees paid to insurance companyUSD $1,965
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $94,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,988
Amount paid for insurance broker fees1965
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 12
Insurance contract or identification number30025262
Number of Individuals Covered109
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $318
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $318
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number03292A
Policy instance 11
Insurance contract or identification number03292A
Number of Individuals Covered2
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $22
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )
Policy contract number00401365
Policy instance 1
Insurance contract or identification number00401365
Number of Individuals Covered406
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Other welfare benefits providedPOS
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 numberOK 965553
Policy instance 2
Insurance contract or identification numberOK 965553
Number of Individuals Covered237
Insurance policy start date2020-04-01
Insurance policy end date2021-04-01
Total amount of commissions paid to insurance brokerUSD $447
Total amount of fees paid to insurance companyUSD $60
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $4,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $447
Amount paid for insurance broker fees60
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963926
Policy instance 5
Insurance contract or identification numberFLX963926
Number of Individuals Covered237
Insurance policy start date2020-04-01
Insurance policy end date2021-04-01
Total amount of commissions paid to insurance brokerUSD $7,330
Total amount of fees paid to insurance companyUSD $591
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $78,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,330
Amount paid for insurance broker fees591
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYD074864
Policy instance 6
Insurance contract or identification numberNYD074864
Number of Individuals Covered193
Insurance policy start date2020-04-01
Insurance policy end date2021-04-01
Total amount of commissions paid to insurance brokerUSD $5,429
Total amount of fees paid to insurance companyUSD $719
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $54,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,429
Amount paid for insurance broker fees719
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number03292A
Policy instance 10
Insurance contract or identification number03292A
Number of Individuals Covered2
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,616
Health Insurance Welfare BenefitYes
Other welfare benefits providedEVACUATION
Welfare Benefit Premiums Paid to CarrierUSD $22,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,616
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960824
Policy instance 8
Insurance contract or identification numberVDT960824
Number of Individuals Covered119
Insurance policy start date2020-04-01
Insurance policy end date2021-04-01
Total amount of commissions paid to insurance brokerUSD $2,739
Total amount of fees paid to insurance companyUSD $255
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,739
Amount paid for insurance broker fees255
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADDN10845762
Policy instance 9
Insurance contract or identification numberADDN10845762
Number of Individuals Covered90
Insurance policy start date2020-07-01
Insurance policy end date2021-07-01
Total amount of commissions paid to insurance brokerUSD $778
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $7,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $778
Additional information about fees paid to insurance brokerSERVICES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 3
Insurance contract or identification number30025262
Number of Individuals Covered108
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $719
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $719
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0001971
Policy instance 7
Insurance contract or identification number0001971
Number of Individuals Covered436
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,468
Total amount of fees paid to insurance companyUSD $515
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,468
Amount paid for insurance broker fees515
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 750929
Policy instance 4
Insurance contract or identification numberLK 750929
Number of Individuals Covered11
Insurance policy start date2020-04-01
Insurance policy end date2021-04-01
Total amount of commissions paid to insurance brokerUSD $209
Total amount of fees paid to insurance companyUSD $32
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $209
Amount paid for insurance broker fees32
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0001971
Policy instance 7
Insurance contract or identification number0001971
Number of Individuals Covered463
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,708
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,708
Insurance broker organization code?3
HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )
Policy contract number00401365
Policy instance 1
Insurance contract or identification number00401365
Number of Individuals Covered439
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Other welfare benefits providedPOS
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 numberOK 965553
Policy instance 2
Insurance contract or identification numberOK 965553
Number of Individuals Covered249
Insurance policy start date2019-04-01
Insurance policy end date2020-04-01
Total amount of commissions paid to insurance brokerUSD $498
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $6,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $498
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 3
Insurance contract or identification number30025262
Number of Individuals Covered112
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,069
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,069
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 750929
Policy instance 4
Insurance contract or identification numberLK 750929
Number of Individuals Covered13
Insurance policy start date2019-04-01
Insurance policy end date2020-04-01
Total amount of commissions paid to insurance brokerUSD $260
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $260
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 12
Insurance contract or identification number30025262
Number of Individuals Covered3
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Vision Insurance Welfare BenefitYes
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 numberFLX963926
Policy instance 5
Insurance contract or identification numberFLX963926
Number of Individuals Covered249
Insurance policy start date2019-04-01
Insurance policy end date2020-04-01
Total amount of commissions paid to insurance brokerUSD $5,943
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $80,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,943
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960824
Policy instance 8
Insurance contract or identification numberVDT960824
Number of Individuals Covered122
Insurance policy start date2019-04-01
Insurance policy end date2020-04-01
Total amount of commissions paid to insurance brokerUSD $5,632
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,632
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberN10845762
Policy instance 9
Insurance contract or identification numberN10845762
Number of Individuals Covered46
Insurance policy start date2019-07-01
Insurance policy end date2020-07-01
Total amount of commissions paid to insurance brokerUSD $778
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $7,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $778
Additional information about fees paid to insurance brokerSERVICES
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number03292A
Policy instance 10
Insurance contract or identification number03292A
Number of Individuals Covered2
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,223
Health Insurance Welfare BenefitYes
Other welfare benefits providedEVACUATION
Welfare Benefit Premiums Paid to CarrierUSD $52,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,223
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number03292A
Policy instance 11
Insurance contract or identification number03292A
Number of Individuals Covered2
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $1,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYD074864
Policy instance 6
Insurance contract or identification numberNYD074864
Number of Individuals Covered201
Insurance policy start date2019-04-01
Insurance policy end date2020-04-01
Total amount of commissions paid to insurance brokerUSD $7,996
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $79,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,996
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 3
Insurance contract or identification number30025262
Number of Individuals Covered113
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,623
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 numberOK 965553
Policy instance 2
Insurance contract or identification numberOK 965553
Number of Individuals Covered277
Insurance policy start date2018-04-01
Insurance policy end date2019-04-01
Total amount of commissions paid to insurance brokerUSD $682
Total amount of fees paid to insurance companyUSD $65
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $6,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $682
Amount paid for insurance broker fees65
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )
Policy contract number00401365
Policy instance 1
Insurance contract or identification number00401365
Number of Individuals Covered454
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Other welfare benefits providedPOS
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 numberLK 750929
Policy instance 4
Insurance contract or identification numberLK 750929
Number of Individuals Covered13
Insurance policy start date2018-04-01
Insurance policy end date2019-04-01
Total amount of commissions paid to insurance brokerUSD $295
Total amount of fees paid to insurance companyUSD $24
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $295
Amount paid for insurance broker fees24
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963926
Policy instance 5
Insurance contract or identification numberFLX963926
Number of Individuals Covered277
Insurance policy start date2018-04-01
Insurance policy end date2019-04-01
Total amount of commissions paid to insurance brokerUSD $10,916
Total amount of fees paid to insurance companyUSD $977
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $114,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,916
Amount paid for insurance broker fees977
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYD074864
Policy instance 6
Insurance contract or identification numberNYD074864
Number of Individuals Covered224
Insurance policy start date2018-04-01
Insurance policy end date2019-04-01
Total amount of commissions paid to insurance brokerUSD $6,278
Total amount of fees paid to insurance companyUSD $423
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $62,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,278
Amount paid for insurance broker fees423
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0001971
Policy instance 7
Insurance contract or identification number0001971
Number of Individuals Covered466
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,831
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,831
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960824
Policy instance 8
Insurance contract or identification numberVDT960824
Number of Individuals Covered134
Insurance policy start date2018-04-01
Insurance policy end date2019-04-01
Total amount of commissions paid to insurance brokerUSD $4,243
Total amount of fees paid to insurance companyUSD $278
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,243
Amount paid for insurance broker fees278
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N10845762R
Policy instance 9
Insurance contract or identification numberADD N10845762R
Number of Individuals Covered50
Insurance policy start date2018-07-01
Insurance policy end date2019-07-01
Total amount of commissions paid to insurance brokerUSD $778
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $7,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $778
Additional information about fees paid to insurance brokerSERVICES
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number03292A
Policy instance 10
Insurance contract or identification number03292A
Number of Individuals Covered3
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $4,734
Health Insurance Welfare BenefitYes
Other welfare benefits providedEVACUATION
Welfare Benefit Premiums Paid to CarrierUSD $59,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,734
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number03292A
Policy instance 11
Insurance contract or identification number03292A
Number of Individuals Covered3
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $115
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $1,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $115
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 12
Insurance contract or identification number30025262
Number of Individuals Covered3
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,021
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,021
Additional information about fees paid to insurance brokerSALES/SERVICE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYD074864
Policy instance 6
Insurance contract or identification numberNYD074864
Number of Individuals Covered223
Insurance policy start date2017-04-01
Insurance policy end date2018-04-01
Total amount of commissions paid to insurance brokerUSD $4,617
Total amount of fees paid to insurance companyUSD $840
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $46,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,617
Amount paid for insurance broker fees840
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NA
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963926
Policy instance 5
Insurance contract or identification numberFLX963926
Number of Individuals Covered268
Insurance policy start date2017-04-01
Insurance policy end date2018-04-01
Total amount of commissions paid to insurance brokerUSD $8,945
Total amount of fees paid to insurance companyUSD $2,075
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $93,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,945
Amount paid for insurance broker fees2075
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NA
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 750929
Policy instance 4
Insurance contract or identification numberLK 750929
Number of Individuals Covered11
Insurance policy start date2017-04-01
Insurance policy end date2018-04-01
Total amount of commissions paid to insurance brokerUSD $218
Total amount of fees paid to insurance companyUSD $52
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $218
Amount paid for insurance broker fees52
Additional information about fees paid to insurance brokerSALES & SERVICE SALES AND SERVICE
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NA
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30025262
Policy instance 3
Insurance contract or identification number30025262
Number of Individuals Covered110
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,008
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $710
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0001971
Policy instance 7
Insurance contract or identification number0001971
Number of Individuals Covered508
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,053
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,053
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NATIONAL, IN
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960824
Policy instance 8
Insurance contract or identification numberVDT960824
Number of Individuals Covered140
Insurance policy start date2017-04-01
Insurance policy end date2018-04-01
Total amount of commissions paid to insurance brokerUSD $3,811
Total amount of fees paid to insurance companyUSD $616
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,811
Amount paid for insurance broker fees616
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NA
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number03292A
Policy instance 10
Insurance contract or identification number03292A
Number of Individuals Covered4
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,380
Health Insurance Welfare BenefitYes
Other welfare benefits providedEVACUATION
Welfare Benefit Premiums Paid to CarrierUSD $54,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,380
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES MI
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberGLM N10845762
Policy instance 9
Insurance contract or identification numberGLM N10845762
Number of Individuals Covered73
Insurance policy start date2017-07-01
Insurance policy end date2018-07-01
Total amount of commissions paid to insurance brokerUSD $778
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $4,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $778
Additional information about fees paid to insurance brokerSERVICES
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NATIONAL
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number03292A
Policy instance 11
Insurance contract or identification number03292A
Number of Individuals Covered4
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $111
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $1,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $111
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES MI
HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )
Policy contract number00401365
Policy instance 1
Insurance contract or identification number00401365
Number of Individuals Covered481
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Other welfare benefits providedPOS
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 numberOK 965553
Policy instance 2
Insurance contract or identification numberOK 965553
Number of Individuals Covered268
Insurance policy start date2017-04-01
Insurance policy end date2018-04-01
Total amount of commissions paid to insurance brokerUSD $589
Total amount of fees paid to insurance companyUSD $141
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $5,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $589
Amount paid for insurance broker fees141
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES

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