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FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 401k Plan overview

Plan NameFULTON BELLOWS, LLC WELFARE BENEFITS PLAN
Plan identification number 502

FULTON BELLOWS, LLC WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

FULTON BELLOWS, LLC has sponsored the creation of one or more 401k plans.

Company Name:FULTON BELLOWS, LLC
Employer identification number (EIN):201395049
NAIC Classification:339900

Additional information about FULTON BELLOWS, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 3778559

More information about FULTON BELLOWS, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FULTON BELLOWS, LLC WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01
5022021-01-01
5022020-08-01
5022019-08-01
5022018-08-01
5022017-08-01DAWN CAMERON DAWN CAMERON2019-02-15
5022016-08-01DAWN CAMERON
5022015-08-01DAWN CAMERON DAWN CAMERON2017-01-23
5022014-08-01DAWN CAMERON
5022013-08-01DAWN CAMERON
5022012-08-01DAWN CAMERON

Plan Statistics for FULTON BELLOWS, LLC WELFARE BENEFITS PLAN

401k plan membership statisitcs for FULTON BELLOWS, LLC WELFARE BENEFITS PLAN

Measure Date Value
2022: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01118
Total number of active participants reported on line 7a of the Form 55002022-01-01127
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 participants2022-01-01127
2021: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01118
Total number of active participants reported on line 7a of the Form 55002021-01-01115
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 participants2021-01-01115
2020: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-08-01117
Total number of active participants reported on line 7a of the Form 55002020-08-01118
Number of retired or separated participants receiving benefits2020-08-010
Number of other retired or separated participants entitled to future benefits2020-08-010
Total of all active and inactive participants2020-08-01118
2019: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-08-01107
Total number of active participants reported on line 7a of the Form 55002019-08-01117
Number of retired or separated participants receiving benefits2019-08-010
Number of other retired or separated participants entitled to future benefits2019-08-010
Total of all active and inactive participants2019-08-01117
2018: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01104
Total number of active participants reported on line 7a of the Form 55002018-08-01107
Total of all active and inactive participants2018-08-01107
Total participants2018-08-01107
2017: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01113
Total number of active participants reported on line 7a of the Form 55002017-08-01102
Number of retired or separated participants receiving benefits2017-08-012
Number of other retired or separated participants entitled to future benefits2017-08-010
Total of all active and inactive participants2017-08-01104
2016: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01134
Total number of active participants reported on line 7a of the Form 55002016-08-01112
Number of retired or separated participants receiving benefits2016-08-011
Number of other retired or separated participants entitled to future benefits2016-08-010
Total of all active and inactive participants2016-08-01113
2015: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-08-01141
Total number of active participants reported on line 7a of the Form 55002015-08-01133
Number of retired or separated participants receiving benefits2015-08-011
Number of other retired or separated participants entitled to future benefits2015-08-010
Total of all active and inactive participants2015-08-01134
2014: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-08-01118
Total number of active participants reported on line 7a of the Form 55002014-08-01141
Total of all active and inactive participants2014-08-01141
Total participants2014-08-010
2013: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-08-01118
Total number of active participants reported on line 7a of the Form 55002013-08-01118
Total of all active and inactive participants2013-08-01118
Total participants2013-08-010
2012: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-08-01122
Total number of active participants reported on line 7a of the Form 55002012-08-01118
Total of all active and inactive participants2012-08-01118
Total participants2012-08-010

Form 5500 Responses for FULTON BELLOWS, LLC WELFARE BENEFITS PLAN

2022: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-08-01Type of plan entitySingle employer plan
2020-08-01Submission has been amendedNo
2020-08-01This submission is the final filingNo
2020-08-01This return/report is a short plan year return/report (less than 12 months)Yes
2020-08-01Plan is a collectively bargained planNo
2020-08-01Plan funding arrangement – InsuranceYes
2020-08-01Plan benefit arrangement – InsuranceYes
2019: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Submission has been amendedNo
2019-08-01This submission is the final filingNo
2019-08-01This return/report is a short plan year return/report (less than 12 months)No
2019-08-01Plan is a collectively bargained planNo
2019-08-01Plan funding arrangement – InsuranceYes
2019-08-01Plan benefit arrangement – InsuranceYes
2018: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Plan funding arrangement – InsuranceYes
2018-08-01Plan benefit arrangement – InsuranceYes
2017: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Submission has been amendedNo
2017-08-01This submission is the final filingNo
2017-08-01This return/report is a short plan year return/report (less than 12 months)No
2017-08-01Plan is a collectively bargained planNo
2017-08-01Plan funding arrangement – General assets of the sponsorYes
2017-08-01Plan benefit arrangement – InsuranceYes
2017-08-01Plan benefit arrangement – General assets of the sponsorYes
2016: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-08-01Type of plan entitySingle employer plan
2016-08-01Submission has been amendedNo
2016-08-01This submission is the final filingNo
2016-08-01This return/report is a short plan year return/report (less than 12 months)No
2016-08-01Plan is a collectively bargained planNo
2016-08-01Plan funding arrangement – General assets of the sponsorYes
2016-08-01Plan benefit arrangement – InsuranceYes
2016-08-01Plan benefit arrangement – General assets of the sponsorYes
2015: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-08-01Type of plan entitySingle employer plan
2015-08-01Submission has been amendedNo
2015-08-01This submission is the final filingNo
2015-08-01This return/report is a short plan year return/report (less than 12 months)No
2015-08-01Plan is a collectively bargained planNo
2015-08-01Plan funding arrangement – General assets of the sponsorYes
2015-08-01Plan benefit arrangement – InsuranceYes
2015-08-01Plan benefit arrangement – General assets of the sponsorYes
2014: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-08-01Type of plan entitySingle employer plan
2014-08-01Plan funding arrangement – General assets of the sponsorYes
2014-08-01Plan benefit arrangement – InsuranceYes
2013: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-08-01Type of plan entitySingle employer plan
2013-08-01Plan funding arrangement – General assets of the sponsorYes
2013-08-01Plan benefit arrangement – InsuranceYes
2012: FULTON BELLOWS, LLC WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-08-01Type of plan entitySingle employer plan
2012-08-01First time form 5500 has been submittedYes
2012-08-01Plan funding arrangement – General assets of the sponsorYes
2012-08-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10120361001
Policy instance 3
Insurance contract or identification number10120361001
Number of Individuals Covered174
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,204
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 $12,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,204
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract numberMULTIPLE
Policy instance 2
Insurance contract or identification numberMULTIPLE
Number of Individuals Covered127
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $20,951
Total amount of fees paid to insurance companyUSD $3,739
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $155,296
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,951
Amount paid for insurance broker fees3739
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number120893
Policy instance 1
Insurance contract or identification number120893
Number of Individuals Covered193
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $37,520
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $652,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,520
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10120361001
Policy instance 3
Insurance contract or identification number10120361001
Number of Individuals Covered162
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,198
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 $10,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $832
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract numberMULTIPLE
Policy instance 2
Insurance contract or identification numberMULTIPLE
Number of Individuals Covered118
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $18,294
Total amount of fees paid to insurance companyUSD $4,172
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $135,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,294
Amount paid for insurance broker fees4172
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number120893
Policy instance 1
Insurance contract or identification number120893
Number of Individuals Covered197
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $37,475
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $623,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,475
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number120893
Policy instance 1
Insurance contract or identification number120893
Number of Individuals Covered186
Insurance policy start date2020-08-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $15,339
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $249,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,339
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerACQ/RET
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract numberMULTIPLE
Policy instance 2
Insurance contract or identification numberMULTIPLE
Number of Individuals Covered118
Insurance policy start date2020-08-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10,202
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $75,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,113
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10120361001
Policy instance 3
Insurance contract or identification number10120361001
Number of Individuals Covered159
Insurance policy start date2020-08-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $448
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 $4,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $448
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5945658
Policy instance 4
Insurance contract or identification number5945658
Number of Individuals Covered0
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $2,103
Total amount of fees paid to insurance companyUSD $299
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $41
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,103
Amount paid for insurance broker fees299
Additional information about fees paid to insurance brokerCOMMISSIONS/FEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10120361001
Policy instance 3
Insurance contract or identification number10120361001
Number of Individuals Covered156
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $1,180
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 $11,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,083
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMM
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract numberMULTIPLE
Policy instance 2
Insurance contract or identification numberMULTIPLE
Number of Individuals Covered117
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $21,226
Total amount of fees paid to insurance companyUSD $4,867
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $157,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,226
Amount paid for insurance broker fees4867
Additional information about fees paid to insurance brokerCOMMISSIONS/FEES
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number120893
Policy instance 1
Insurance contract or identification number120893
Number of Individuals Covered184
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $34,207
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $607,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,207
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerACQ/RET
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5945658
Policy instance 2
Insurance contract or identification number5945658
Number of Individuals Covered271
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $17,324
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $153,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,688
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number120893
Policy instance 1
Insurance contract or identification number120893
Number of Individuals Covered107
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $36,605
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $739,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,994
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05945658
Policy instance 2
Insurance contract or identification numberKM05945658
Number of Individuals Covered257
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $10,508
Total amount of fees paid to insurance companyUSD $2,596
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $126,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number120893
Policy instance 1
Insurance contract or identification number120893
Number of Individuals Covered185
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $35,078
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $732,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number120893
Policy instance 2
Insurance contract or identification number120893
Number of Individuals Covered223
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $41,529
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHRA
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 $771,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,833
Insurance broker organization code?3
Insurance broker nameMARY ANNE FITZGERALD
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5472515
Policy instance 1
Insurance contract or identification number5472515
Number of Individuals Covered168
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $19,135
Total amount of fees paid to insurance companyUSD $1,545
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT & CRITICAL ILLNESS
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 $126,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,724
Amount paid for insurance broker fees1545
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
Insurance broker organization code?3
Insurance broker nameAON CONSULTING INC.
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5472515
Policy instance 1
Insurance contract or identification number5472515
Number of Individuals Covered141
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $23,029
Total amount of fees paid to insurance companyUSD $3,953
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT & CRITICAL ILLNESS INS
Welfare Benefit Premiums Paid to CarrierUSD $124,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,029
Amount paid for insurance broker fees3953
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
Insurance broker organization code?3
Insurance broker namePMG BENEFITS CONSULTANTS LLC
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number120893
Policy instance 2
Insurance contract or identification number120893
Number of Individuals Covered232
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $48,408
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Other welfare benefits providedBCBS ADMINISTERS HRA ACCOUNTS
Welfare Benefit Premiums Paid to CarrierUSD $780,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,408
Insurance broker organization code?3
Insurance broker nameRYAN GROSE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10163009 00000
Policy instance 2
Insurance contract or identification number10163009 00000
Number of Individuals Covered117
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $2,687
Total amount of fees paid to insurance companyUSD $521
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,687
Amount paid for insurance broker fees521
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker namePMG BENEFITS CONSULTANTS LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10163008 00000
Policy instance 1
Insurance contract or identification number10163008 00000
Number of Individuals Covered118
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $2,887
Total amount of fees paid to insurance companyUSD $568
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,887
Amount paid for insurance broker fees568
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker namePMG BENEFITS CONSULTANTS LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10163008 00000
Policy instance 4
Insurance contract or identification number10163008 00000
Number of Individuals Covered118
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $2,609
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,609
Insurance broker organization code?3
Insurance broker namePMG BENEFITS CONSULTANTS LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10163009 00000
Policy instance 3
Insurance contract or identification number10163009 00000
Number of Individuals Covered118
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $2,432
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,432
Insurance broker organization code?3
Insurance broker namePMG BENEFITS CONSULTANTS LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10163010 00000
Policy instance 2
Insurance contract or identification number10163010 00000
Number of Individuals Covered92
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $3,796
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,796
Insurance broker organization code?3
Insurance broker namePMG BENEFITS CONSULTANTS LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400001000 15528
Policy instance 1
Insurance contract or identification number400001000 15528
Number of Individuals Covered46
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $2,352
Other welfare benefits providedOPTIONAL ADDITIONAL LIFE INSURANCE
Welfare Benefit Premiums Paid to CarrierUSD $17,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,352
Insurance broker organization code?3
Insurance broker namePMG BENEFITS CONSULTANTS LLC

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