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SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 401k Plan overview

Plan NameSCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN
Plan identification number 501

SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover

401k Sponsoring company profile

SCHWARTZ BROTHERS RESTAURANTS has sponsored the creation of one or more 401k plans.

Company Name:SCHWARTZ BROTHERS RESTAURANTS
Employer identification number (EIN):201335083
NAIC Classification:722511
NAIC Description:Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-03-01
5012021-03-01
5012020-03-01
5012019-03-01
5012018-03-01
5012017-03-01BRIAN TEGEN
5012016-03-01BRIAN TEGEN
5012015-03-01BRIAN TEGEN
5012014-03-01BRIAN TEGEN
5012013-03-01BRIAN TEGEN BRIAN TEGEN2014-09-16
5012012-03-01BRIAN TEGEN
5012011-03-01JILL FARLEY
5012010-03-01JILL FARLEY
5012009-03-01JILL FARLEY

Plan Statistics for SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN

401k plan membership statisitcs for SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN

Measure Date Value
2022: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-03-01205
Total number of active participants reported on line 7a of the Form 55002022-03-01199
Number of retired or separated participants receiving benefits2022-03-010
Number of other retired or separated participants entitled to future benefits2022-03-010
Total of all active and inactive participants2022-03-01199
2021: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-03-01207
Total number of active participants reported on line 7a of the Form 55002021-03-01204
Number of retired or separated participants receiving benefits2021-03-011
Number of other retired or separated participants entitled to future benefits2021-03-010
Total of all active and inactive participants2021-03-01205
2020: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-03-01255
Total number of active participants reported on line 7a of the Form 55002020-03-01202
Number of retired or separated participants receiving benefits2020-03-015
Total of all active and inactive participants2020-03-01207
2019: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01261
Total number of active participants reported on line 7a of the Form 55002019-03-01249
Number of retired or separated participants receiving benefits2019-03-016
Number of other retired or separated participants entitled to future benefits2019-03-010
Total of all active and inactive participants2019-03-01255
2018: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-03-01293
Total number of active participants reported on line 7a of the Form 55002018-03-01257
Number of retired or separated participants receiving benefits2018-03-014
Total of all active and inactive participants2018-03-01261
2017: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-03-01293
Total number of active participants reported on line 7a of the Form 55002017-03-01293
Number of retired or separated participants receiving benefits2017-03-014
Number of other retired or separated participants entitled to future benefits2017-03-010
Total of all active and inactive participants2017-03-01297
2016: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-03-01439
Total number of active participants reported on line 7a of the Form 55002016-03-01293
Number of retired or separated participants receiving benefits2016-03-012
Number of other retired or separated participants entitled to future benefits2016-03-010
Total of all active and inactive participants2016-03-01295
2015: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-03-01452
Total number of active participants reported on line 7a of the Form 55002015-03-01435
Number of retired or separated participants receiving benefits2015-03-014
Number of other retired or separated participants entitled to future benefits2015-03-010
Total of all active and inactive participants2015-03-01439
2014: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-03-01358
Total number of active participants reported on line 7a of the Form 55002014-03-01452
Number of retired or separated participants receiving benefits2014-03-010
Number of other retired or separated participants entitled to future benefits2014-03-010
Total of all active and inactive participants2014-03-01452
2013: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-03-01399
Total number of active participants reported on line 7a of the Form 55002013-03-01352
Number of retired or separated participants receiving benefits2013-03-016
Number of other retired or separated participants entitled to future benefits2013-03-010
Total of all active and inactive participants2013-03-01358
2012: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-03-01365
Total number of active participants reported on line 7a of the Form 55002012-03-01395
Number of retired or separated participants receiving benefits2012-03-014
Number of other retired or separated participants entitled to future benefits2012-03-010
Total of all active and inactive participants2012-03-01399
2011: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-03-01366
Total number of active participants reported on line 7a of the Form 55002011-03-01361
Number of retired or separated participants receiving benefits2011-03-014
Number of other retired or separated participants entitled to future benefits2011-03-010
Total of all active and inactive participants2011-03-01365
2010: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2010 401k membership
Total participants, beginning-of-year2010-03-01320
Total number of active participants reported on line 7a of the Form 55002010-03-01360
Number of retired or separated participants receiving benefits2010-03-016
Number of other retired or separated participants entitled to future benefits2010-03-010
Total of all active and inactive participants2010-03-01366
2009: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year2009-03-01357
Total number of active participants reported on line 7a of the Form 55002009-03-01313
Number of retired or separated participants receiving benefits2009-03-017
Number of other retired or separated participants entitled to future benefits2009-03-010
Total of all active and inactive participants2009-03-01320

Form 5500 Responses for SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN

2022: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2022 form 5500 responses
2022-03-01Type of plan entitySingle employer plan
2022-03-01Submission has been amendedNo
2022-03-01This submission is the final filingNo
2022-03-01This return/report is a short plan year return/report (less than 12 months)No
2022-03-01Plan is a collectively bargained planNo
2022-03-01Plan funding arrangement – InsuranceYes
2022-03-01Plan funding arrangement – General assets of the sponsorYes
2022-03-01Plan benefit arrangement – InsuranceYes
2022-03-01Plan benefit arrangement – General assets of the sponsorYes
2021: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2021 form 5500 responses
2021-03-01Type of plan entitySingle employer plan
2021-03-01Submission has been amendedNo
2021-03-01This submission is the final filingNo
2021-03-01This return/report is a short plan year return/report (less than 12 months)No
2021-03-01Plan is a collectively bargained planNo
2021-03-01Plan funding arrangement – InsuranceYes
2021-03-01Plan funding arrangement – General assets of the sponsorYes
2021-03-01Plan benefit arrangement – InsuranceYes
2021-03-01Plan benefit arrangement – General assets of the sponsorYes
2020: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2020 form 5500 responses
2020-03-01Type of plan entitySingle employer plan
2020-03-01Submission has been amendedNo
2020-03-01This submission is the final filingNo
2020-03-01This return/report is a short plan year return/report (less than 12 months)No
2020-03-01Plan is a collectively bargained planNo
2020-03-01Plan funding arrangement – InsuranceYes
2020-03-01Plan funding arrangement – General assets of the sponsorYes
2020-03-01Plan benefit arrangement – InsuranceYes
2020-03-01Plan benefit arrangement – General assets of the sponsorYes
2019: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01Submission has been amendedNo
2019-03-01This submission is the final filingNo
2019-03-01This return/report is a short plan year return/report (less than 12 months)No
2019-03-01Plan is a collectively bargained planNo
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan funding arrangement – General assets of the sponsorYes
2019-03-01Plan benefit arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – General assets of the sponsorYes
2018: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2018 form 5500 responses
2018-03-01Type of plan entitySingle employer plan
2018-03-01Submission has been amendedNo
2018-03-01This submission is the final filingNo
2018-03-01This return/report is a short plan year return/report (less than 12 months)No
2018-03-01Plan is a collectively bargained planNo
2018-03-01Plan funding arrangement – InsuranceYes
2018-03-01Plan funding arrangement – General assets of the sponsorYes
2018-03-01Plan benefit arrangement – InsuranceYes
2018-03-01Plan benefit arrangement – General assets of the sponsorYes
2017: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2017 form 5500 responses
2017-03-01Type of plan entitySingle employer plan
2017-03-01Submission has been amendedNo
2017-03-01This submission is the final filingNo
2017-03-01This return/report is a short plan year return/report (less than 12 months)No
2017-03-01Plan is a collectively bargained planNo
2017-03-01Plan funding arrangement – InsuranceYes
2017-03-01Plan funding arrangement – General assets of the sponsorYes
2017-03-01Plan benefit arrangement – InsuranceYes
2017-03-01Plan benefit arrangement – General assets of the sponsorYes
2016: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2016 form 5500 responses
2016-03-01Type of plan entitySingle employer plan
2016-03-01Submission has been amendedNo
2016-03-01This submission is the final filingNo
2016-03-01This return/report is a short plan year return/report (less than 12 months)No
2016-03-01Plan is a collectively bargained planNo
2016-03-01Plan funding arrangement – InsuranceYes
2016-03-01Plan funding arrangement – General assets of the sponsorYes
2016-03-01Plan benefit arrangement – InsuranceYes
2016-03-01Plan benefit arrangement – General assets of the sponsorYes
2015: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2015 form 5500 responses
2015-03-01Type of plan entitySingle employer plan
2015-03-01Submission has been amendedNo
2015-03-01This submission is the final filingNo
2015-03-01This return/report is a short plan year return/report (less than 12 months)No
2015-03-01Plan is a collectively bargained planNo
2015-03-01Plan funding arrangement – InsuranceYes
2015-03-01Plan funding arrangement – General assets of the sponsorYes
2015-03-01Plan benefit arrangement – InsuranceYes
2015-03-01Plan benefit arrangement – General assets of the sponsorYes
2014: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2014 form 5500 responses
2014-03-01Type of plan entitySingle employer plan
2014-03-01Submission has been amendedNo
2014-03-01This submission is the final filingNo
2014-03-01This return/report is a short plan year return/report (less than 12 months)No
2014-03-01Plan is a collectively bargained planNo
2014-03-01Plan funding arrangement – InsuranceYes
2014-03-01Plan funding arrangement – General assets of the sponsorYes
2014-03-01Plan benefit arrangement – InsuranceYes
2014-03-01Plan benefit arrangement – General assets of the sponsorYes
2013: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2013 form 5500 responses
2013-03-01Type of plan entitySingle employer plan
2013-03-01Submission has been amendedNo
2013-03-01This submission is the final filingNo
2013-03-01This return/report is a short plan year return/report (less than 12 months)No
2013-03-01Plan is a collectively bargained planNo
2013-03-01Plan funding arrangement – InsuranceYes
2013-03-01Plan funding arrangement – General assets of the sponsorYes
2013-03-01Plan benefit arrangement – InsuranceYes
2013-03-01Plan benefit arrangement – General assets of the sponsorYes
2012: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2012 form 5500 responses
2012-03-01Type of plan entitySingle employer plan
2012-03-01Submission has been amendedNo
2012-03-01This submission is the final filingNo
2012-03-01This return/report is a short plan year return/report (less than 12 months)No
2012-03-01Plan is a collectively bargained planNo
2012-03-01Plan funding arrangement – InsuranceYes
2012-03-01Plan funding arrangement – General assets of the sponsorYes
2012-03-01Plan benefit arrangement – InsuranceYes
2012-03-01Plan benefit arrangement – General assets of the sponsorYes
2011: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2011 form 5500 responses
2011-03-01Type of plan entitySingle employer plan
2011-03-01Submission has been amendedNo
2011-03-01This submission is the final filingNo
2011-03-01This return/report is a short plan year return/report (less than 12 months)No
2011-03-01Plan is a collectively bargained planNo
2011-03-01Plan funding arrangement – InsuranceYes
2011-03-01Plan funding arrangement – General assets of the sponsorYes
2011-03-01Plan benefit arrangement – InsuranceYes
2011-03-01Plan benefit arrangement – General assets of the sponsorYes
2010: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2010 form 5500 responses
2010-03-01Type of plan entitySingle employer plan
2010-03-01Submission has been amendedYes
2010-03-01This submission is the final filingNo
2010-03-01This return/report is a short plan year return/report (less than 12 months)No
2010-03-01Plan is a collectively bargained planNo
2010-03-01Plan funding arrangement – InsuranceYes
2010-03-01Plan funding arrangement – General assets of the sponsorYes
2010-03-01Plan benefit arrangement – InsuranceYes
2010-03-01Plan benefit arrangement – General assets of the sponsorYes
2009: SCHWARTZ BROTHERS RESTAURANTS TEAM MEMBER HEALTH CARE PLAN 2009 form 5500 responses
2009-03-01Type of plan entitySingle employer plan
2009-03-01Submission has been amendedNo
2009-03-01This submission is the final filingNo
2009-03-01This return/report is a short plan year return/report (less than 12 months)No
2009-03-01Plan is a collectively bargained planNo
2009-03-01Plan funding arrangement – InsuranceYes
2009-03-01Plan funding arrangement – General assets of the sponsorYes
2009-03-01Plan benefit arrangement – InsuranceYes
2009-03-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number466230
Policy instance 3
Insurance contract or identification number466230
Number of Individuals Covered199
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $2,123
Total amount of fees paid to insurance companyUSD $317
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,123
Amount paid for insurance broker fees317
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30024563
Policy instance 2
Insurance contract or identification number30024563
Number of Individuals Covered154
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $1,004
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,004
Insurance broker organization code?3
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL34706
Policy instance 1
Insurance contract or identification numberHCL34706
Number of Individuals Covered198
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $4,810
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $192,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees4810
Additional information about fees paid to insurance brokerOVERRIDE PAYMENTS
Insurance broker organization code?5
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number466230
Policy instance 1
Insurance contract or identification number466230
Number of Individuals Covered200
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $2,043
Total amount of fees paid to insurance companyUSD $335
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,043
Amount paid for insurance broker fees335
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL34706
Policy instance 2
Insurance contract or identification numberHCL34706
Number of Individuals Covered204
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $4,671
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $186,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees4671
Additional information about fees paid to insurance brokerOVERRIDE PAYMENTS
Insurance broker organization code?5
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30024563
Policy instance 3
Insurance contract or identification number30024563
Number of Individuals Covered151
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $1,086
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $16,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,086
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number466230
Policy instance 1
Insurance contract or identification number466230
Number of Individuals Covered190
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $1,776
Total amount of fees paid to insurance companyUSD $228
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,776
Amount paid for insurance broker fees228
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract number
Policy instance 2
Number of Individuals Covered202
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $4,358
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $174,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees4358
Additional information about fees paid to insurance brokerOVERRIDE PAYMENTS
Insurance broker organization code?5
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30024563
Policy instance 3
Insurance contract or identification number30024563
Number of Individuals Covered144
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $843
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $843
Insurance broker organization code?3
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract number
Policy instance 3
Number of Individuals Covered249
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $5,391
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $285,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,391
Insurance broker organization code?5
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number466230
Policy instance 2
Insurance contract or identification number466230
Number of Individuals Covered246
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $2,339
Total amount of fees paid to insurance companyUSD $348
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,339
Amount paid for insurance broker fees348
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30024563
Policy instance 1
Insurance contract or identification number30024563
Number of Individuals Covered178
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $1,102
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,102
Insurance broker organization code?3
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract numberUNI-201895
Policy instance 3
Insurance contract or identification numberUNI-201895
Number of Individuals Covered279
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $9,931
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $397,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees9931
Additional information about fees paid to insurance brokerFEE
Insurance broker organization code?5
Insurance broker nameHEALTHCARE MGMT ADMINISTRATORS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number466230
Policy instance 2
Insurance contract or identification number466230
Number of Individuals Covered293
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $2,224
Total amount of fees paid to insurance companyUSD $333
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,224
Amount paid for insurance broker fees333
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameMCM
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30024563
Policy instance 1
Insurance contract or identification number30024563
Number of Individuals Covered174
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $1,107
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,107
Insurance broker organization code?3
Insurance broker nameASSURED PARTNERS OF WASHINGTON
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30024563
Policy instance 1
Insurance contract or identification number30024563
Number of Individuals Covered253
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $1,431
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $31,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,431
Insurance broker organization code?3
Insurance broker nameMCM
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract numberUNI-201895
Policy instance 2
Insurance contract or identification numberUNI-201895
Number of Individuals Covered430
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $561,752
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 number466230
Policy instance 3
Insurance contract or identification number466230
Number of Individuals Covered435
Insurance policy start date2015-03-01
Insurance policy end date2016-02-29
Total amount of commissions paid to insurance brokerUSD $3,629
Total amount of fees paid to insurance companyUSD $576
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,629
Amount paid for insurance broker fees576
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameMCM
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract numberUNI-201895
Policy instance 2
Insurance contract or identification numberUNI-201895
Number of Individuals Covered437
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $494,716
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 number466230
Policy instance 3
Insurance contract or identification number466230
Number of Individuals Covered452
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $3,558
Total amount of fees paid to insurance companyUSD $628
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,558
Amount paid for insurance broker fees628
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameMCM
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30024563
Policy instance 1
Insurance contract or identification number30024563
Number of Individuals Covered264
Insurance policy start date2014-03-01
Insurance policy end date2015-02-28
Total amount of commissions paid to insurance brokerUSD $1,384
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,384
Insurance broker organization code?3
Insurance broker nameMCM
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number466230
Policy instance 1
Insurance contract or identification number466230
Number of Individuals Covered352
Insurance policy start date2013-04-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $3,512
Total amount of fees paid to insurance companyUSD $1,081
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,512
Amount paid for insurance broker fees1081
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameMCM
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number403566
Policy instance 2
Insurance contract or identification number403566
Number of Individuals Covered351
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $357,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 )
Policy contract number30024563
Policy instance 3
Insurance contract or identification number30024563
Number of Individuals Covered110
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
Total amount of commissions paid to insurance brokerUSD $822
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $822
Insurance broker organization code?3
Insurance broker nameMCM
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 )
Policy contract number30024563
Policy instance 1
Insurance contract or identification number30024563
Number of Individuals Covered98
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $786
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $786
Insurance broker organization code?3
Insurance broker nameMCM
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number403566
Policy instance 3
Insurance contract or identification number403566
Number of Individuals Covered336
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $254,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWA05523W
Policy instance 2
Insurance contract or identification numberWA05523W
Number of Individuals Covered395
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $3,320
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $31,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,320
Insurance broker organization code?3
Insurance broker nameMCM
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWA05523W
Policy instance 2
Insurance contract or identification numberWA05523W
Number of Individuals Covered361
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $2,215
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number403566
Policy instance 1
Insurance contract or identification number403566
Number of Individuals Covered323
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $251,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 )
Policy contract number30024563
Policy instance 3
Insurance contract or identification number30024563
Number of Individuals Covered94
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $767
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL15444
Policy instance 2
Insurance contract or identification numberHCL15444
Number of Individuals Covered329
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $5,095
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $242,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees5095
Additional information about fees paid to insurance brokerCOMMISSION OVERRIDE
Insurance broker organization code?3
Insurance broker nameMCM
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWA05523W
Policy instance 1
Insurance contract or identification numberWA05523W
Number of Individuals Covered360
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $2,391
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,391
Insurance broker organization code?3
Insurance broker nameMCM

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