ETNA SHARED SERVICES, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ETNA SHARED SERVICES WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: ETNA SHARED SERVICES WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-02-01 | 464 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 431 |
| Number of retired or separated participants receiving benefits | 2022-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-02-01 | 0 |
| Total of all active and inactive participants | 2022-02-01 | 431 |
| 2021: ETNA SHARED SERVICES WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-02-01 | 464 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 464 |
| Number of retired or separated participants receiving benefits | 2021-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-02-01 | 0 |
| Total of all active and inactive participants | 2021-02-01 | 465 |
| 2020: ETNA SHARED SERVICES WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 424 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 443 |
| Number of retired or separated participants receiving benefits | 2020-02-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2020-02-01 | 0 |
| Total of all active and inactive participants | 2020-02-01 | 447 |
| 2019: ETNA SHARED SERVICES WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 421 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 424 |
| Number of retired or separated participants receiving benefits | 2019-02-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2019-02-01 | 0 |
| Total of all active and inactive participants | 2019-02-01 | 428 |
| 2018: ETNA SHARED SERVICES WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 397 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 421 |
| Number of retired or separated participants receiving benefits | 2018-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-02-01 | 0 |
| Total of all active and inactive participants | 2018-02-01 | 421 |
| 2017: ETNA SHARED SERVICES WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 323 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 397 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Total of all active and inactive participants | 2017-02-01 | 397 |
| 2016: ETNA SHARED SERVICES WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 316 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 323 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Total of all active and inactive participants | 2016-02-01 | 329 |
| 2015: ETNA SHARED SERVICES WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 227 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 241 |
| Number of retired or separated participants receiving benefits | 2015-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-02-01 | 0 |
| Total of all active and inactive participants | 2015-02-01 | 242 |
| 2014: ETNA SHARED SERVICES WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-02-01 | 246 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-02-01 | 310 |
| Number of retired or separated participants receiving benefits | 2014-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2014-02-01 | 0 |
| Total of all active and inactive participants | 2014-02-01 | 311 |
| 2013: ETNA SHARED SERVICES WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-02-01 | 247 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-02-01 | 246 |
| Number of retired or separated participants receiving benefits | 2013-02-01 | 1 |
| Total of all active and inactive participants | 2013-02-01 | 247 |
| 2011: ETNA SHARED SERVICES WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-02-01 | 219 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-02-01 | 242 |
| Number of retired or separated participants receiving benefits | 2011-02-01 | 2 |
| Total of all active and inactive participants | 2011-02-01 | 244 |
| 2009: ETNA SHARED SERVICES WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-02-01 | 255 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-02-01 | 229 |
| Number of retired or separated participants receiving benefits | 2009-02-01 | 9 |
| Total of all active and inactive participants | 2009-02-01 | 238 |
| 2022: ETNA SHARED SERVICES WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-02-01 | Type of plan entity | Mulitple employer plan |
| 2022-02-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2022-02-01 | Plan funding arrangement – Insurance | Yes |
| 2022-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ETNA SHARED SERVICES WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-02-01 | Type of plan entity | Mulitple employer plan |
| 2021-02-01 | Plan funding arrangement – Insurance | Yes |
| 2021-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ETNA SHARED SERVICES WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Mulitple employer plan |
| 2020-02-01 | Plan funding arrangement – Insurance | Yes |
| 2020-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: ETNA SHARED SERVICES WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Mulitple employer plan |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ETNA SHARED SERVICES WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Mulitple employer plan |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ETNA SHARED SERVICES WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Mulitple employer plan |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ETNA SHARED SERVICES WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Mulitple employer plan |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ETNA SHARED SERVICES WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Mulitple employer plan |
| 2015-02-01 | Submission has been amended | Yes |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ETNA SHARED SERVICES WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-02-01 | Type of plan entity | Mulitple employer plan |
| 2014-02-01 | Plan funding arrangement – Insurance | Yes |
| 2014-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ETNA SHARED SERVICES WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-02-01 | Type of plan entity | Single employer plan |
| 2013-02-01 | Plan funding arrangement – Insurance | Yes |
| 2013-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: ETNA SHARED SERVICES WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-02-01 | Type of plan entity | Single employer plan |
| 2011-02-01 | Submission has been amended | Yes |
| 2011-02-01 | Plan funding arrangement – Insurance | Yes |
| 2011-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: ETNA SHARED SERVICES WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-02-01 | Type of plan entity | Single employer plan |
| 2009-02-01 | Submission has been amended | Yes |
| 2009-02-01 | Plan funding arrangement – Insurance | Yes |
| 2009-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00569904 |
| Policy instance | 5 |
| Insurance contract or identification number | 00569904 | | Number of Individuals Covered | 469 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $41,867 | | Total amount of fees paid to insurance company | USD $11,390 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | OPTIONAL AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $309,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,399 | | Amount paid for insurance broker fees | 11390 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30089134 |
| Policy instance | 4 |
| Insurance contract or identification number | 30089134 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,518 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,230 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,518 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 283 |
| Policy instance | 3 |
| Insurance contract or identification number | 283 | | Number of Individuals Covered | 766 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,379 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,379 | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL35592 |
| Policy instance | 2 |
| Insurance contract or identification number | HCL35592 | | Number of Individuals Covered | 363 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $6,744 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $807,064 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,744 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 223513 |
| Policy instance | 1 |
| Insurance contract or identification number | 223513 | | Number of Individuals Covered | 363 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $101,621 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 97309 | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL35592 |
| Policy instance | 2 |
| Insurance contract or identification number | HCL35592 | | Number of Individuals Covered | 331 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $5,631 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $698,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,631 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 223513 |
| Policy instance | 1 |
| Insurance contract or identification number | 223513 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $101,584 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $101,584 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30089134 |
| Policy instance | 4 |
| Insurance contract or identification number | 30089134 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $1,488 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,617 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,488 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00569904 |
| Policy instance | 5 |
| Insurance contract or identification number | 00569904 | | Number of Individuals Covered | 431 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $88,298 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | OPTIONAL AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $250,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $63,109 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 283 |
| Policy instance | 3 |
| Insurance contract or identification number | 283 | | Number of Individuals Covered | 717 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $12,076 | | Total amount of fees paid to insurance company | USD $361 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,076 | | Amount paid for insurance broker fees | 361 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 223513 |
| Policy instance | 1 |
| Insurance contract or identification number | 223513 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $101,161 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,194 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00569904 |
| Policy instance | 5 |
| Insurance contract or identification number | 00569904 | | Number of Individuals Covered | 406 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $23,795 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | OPTIONAL AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $236,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,935 | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL35592 |
| Policy instance | 2 |
| Insurance contract or identification number | HCL35592 | | Number of Individuals Covered | 307 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $7,354 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $612,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,354 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 283 |
| Policy instance | 3 |
| Insurance contract or identification number | 283 | | Number of Individuals Covered | 619 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $12,084 | | Total amount of fees paid to insurance company | USD $523 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,084 | | Amount paid for insurance broker fees | 523 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30089134 |
| Policy instance | 4 |
| Insurance contract or identification number | 30089134 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $1,312 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,312 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7606825 |
| Policy instance | 2 |
| Insurance contract or identification number | E7606825 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $257 | | Other welfare benefits provided | SUPPLEMENTAL INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $8,052 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $112 |
|
| GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00569904 |
| Policy instance | 9 |
| Insurance contract or identification number | 00569904 | | Number of Individuals Covered | 420 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D INSURANCE | | 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: 39616 ) |
| Policy contract number | 30089134 |
| Policy instance | 8 |
| Insurance contract or identification number | 30089134 | | Number of Individuals Covered | 219 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $1,265 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,882 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,265 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 7 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $10,398 | | Total amount of fees paid to insurance company | USD $1,825 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $86,646 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,398 | | Amount paid for insurance broker fees | 1825 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 6 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $4,216 | | Total amount of fees paid to insurance company | USD $1,182 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,157 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,216 | | Amount paid for insurance broker fees | 1182 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 5 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 579 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $10,602 | | Total amount of fees paid to insurance company | USD $2,019 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $88,349 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,602 | | Amount paid for insurance broker fees | 2019 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 4 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 414 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $1,146 | | Total amount of fees paid to insurance company | USD $230 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,547 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,146 | | Amount paid for insurance broker fees | 230 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 283 |
| Policy instance | 3 |
| Insurance contract or identification number | 283 | | Number of Individuals Covered | 686 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $6,553 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,553 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 223513 |
| Policy instance | 1 |
| Insurance contract or identification number | 223513 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $19,001 | | Total amount of fees paid to insurance company | USD $97,560 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $542,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,589 | | Amount paid for insurance broker fees | 97560 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 9 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $8,367 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $69,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,367 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 8 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $4,476 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,476 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 7 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 551 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $9,383 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,190 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,383 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 07044 |
| Policy instance | 1 |
| Insurance contract or identification number | 07044 | | Number of Individuals Covered | 302 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $19,476 | | Total amount of fees paid to insurance company | USD $87,244 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $553,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,476 | | Amount paid for insurance broker fees | 83933 | | Insurance broker organization code? | 3 |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7606825 |
| Policy instance | 2 |
| Insurance contract or identification number | E7606825 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $236 | | Other welfare benefits provided | SUPPLEMENTAL INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $6,690 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $103 |
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| SVS VISION MANAGED CARE, INC. (National Association of Insurance Commissioners NAIC id number: 11082 ) |
| Policy contract number | 4190 |
| Policy instance | 3 |
| Insurance contract or identification number | 4190 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SVS VISION MANAGED CARE, INC. (National Association of Insurance Commissioners NAIC id number: 11082 ) |
| Policy contract number | 5395 |
| Policy instance | 4 |
| Insurance contract or identification number | 5395 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,535 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 283 |
| Policy instance | 5 |
| Insurance contract or identification number | 283 | | Number of Individuals Covered | 651 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $7,588 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,588 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 6 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 390 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $1,058 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,817 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,058 | | Insurance broker organization code? | 3 |
|
| SVS VISION MANAGED CARE, INC. (National Association of Insurance Commissioners NAIC id number: 11082 ) |
| Policy contract number | 4190 |
| Policy instance | 3 |
| Insurance contract or identification number | 4190 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SVS VISION MANAGED CARE, INC. (National Association of Insurance Commissioners NAIC id number: 11082 ) |
| Policy contract number | 5395 |
| Policy instance | 4 |
| Insurance contract or identification number | 5395 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,674 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 283 |
| Policy instance | 5 |
| Insurance contract or identification number | 283 | | Number of Individuals Covered | 594 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,334 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,334 | | Insurance broker name | THE JAMES B. OSWALD COMPANY |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 7 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 524 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $7,024 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,534 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,024 | | Insurance broker organization code? | 3 | | Insurance broker name | THE JAMES B OSWALD CO |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 6 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 358 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $964 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,032 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $964 | | Insurance broker organization code? | 3 | | Insurance broker name | THE JAMES B OSWALD CO |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 8 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $4,767 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,668 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,767 | | Insurance broker organization code? | 3 | | Insurance broker name | THE JAMES B OSWALD CO |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAY6 |
| Policy instance | 9 |
| Insurance contract or identification number | G000AAY6 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $8,405 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,041 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,405 | | Insurance broker organization code? | 3 | | Insurance broker name | THE JAMES B OSWALD CO |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 07044 |
| Policy instance | 1 |
| Insurance contract or identification number | 07044 | | Number of Individuals Covered | 294 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $19,993 | | Total amount of fees paid to insurance company | USD $84,339 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $573,149 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,835 | | Amount paid for insurance broker fees | 47429 | | Insurance broker name | MARC S BYRNES |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7606825 |
| Policy instance | 2 |
| Insurance contract or identification number | E7606825 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $443 | | Other welfare benefits provided | SUPPLEMENTAL INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $8,415 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $128 | | Insurance broker name | DIANNA LYNN ATCHISON |
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