RIVERSIDE CASINO AND GOLF RESORT, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN
401k plan membership statisitcs for RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN
| Measure | Date | Value |
|---|
| 2016: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 300 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 0 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 0 |
| Total of all active and inactive participants | 2016-07-01 | 0 |
| 2015: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 539 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 306 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 4 |
| Total of all active and inactive participants | 2015-07-01 | 310 |
| 2014: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 288 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 297 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 2 |
| Total of all active and inactive participants | 2014-07-01 | 299 |
| 2013: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 264 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 287 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 1 |
| Total of all active and inactive participants | 2013-07-01 | 288 |
| 2012: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 250 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 262 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 2 |
| Total of all active and inactive participants | 2012-07-01 | 264 |
| 2011: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 238 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 248 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 2 |
| Total of all active and inactive participants | 2011-07-01 | 250 |
| 2010: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-07-01 | 291 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-07-01 | 235 |
| Number of retired or separated participants receiving benefits | 2010-07-01 | 3 |
| Total of all active and inactive participants | 2010-07-01 | 238 |
| 2009: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 281 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 278 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 13 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 0 |
| Total of all active and inactive participants | 2009-07-01 | 291 |
| 2007: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-07-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-07-01 | 264 |
| Total of all active and inactive participants | 2007-07-01 | 264 |
| Measure | Date | Value |
|---|
| 2013 : RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2013 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-06-30 | $119,323 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-06-30 | $94,994 |
| Total income from all sources (including contributions) | 2013-06-30 | $1,814,626 |
| Total of all expenses incurred | 2013-06-30 | $1,838,955 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-06-30 | $1,436,204 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-06-30 | $1,814,626 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-06-30 | $402,751 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-06-30 | No |
| Was this plan covered by a fidelity bond | 2013-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2013-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-06-30 | No |
| Contributions received from participants | 2013-06-30 | $556,044 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2013-06-30 | $119,323 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2013-06-30 | $94,994 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-06-30 | No |
| Value of net income/loss | 2013-06-30 | $-24,329 |
| Value of net assets at end of year (total assets less liabilities) | 2013-06-30 | $-119,323 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-06-30 | $-94,994 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-06-30 | No |
| Contributions received in cash from employer | 2013-06-30 | $1,258,582 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-06-30 | $1,436,204 |
| Contract administrator fees | 2013-06-30 | $402,751 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2013-06-30 | No |
| Did the plan have assets held for investment | 2013-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-06-30 | Unqualified |
| Accountancy firm name | 2013-06-30 | HONKAMP KRUEGER & CO., P.C. |
| Accountancy firm EIN | 2013-06-30 | 420946155 |
| 2012 : RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2012 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-06-30 | $94,994 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-06-30 | $45,263 |
| Total income from all sources (including contributions) | 2012-06-30 | $1,670,037 |
| Total of all expenses incurred | 2012-06-30 | $1,719,768 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-06-30 | $1,362,218 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-06-30 | $1,670,037 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-06-30 | $357,550 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-06-30 | No |
| Was this plan covered by a fidelity bond | 2012-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2012-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-06-30 | No |
| Contributions received from participants | 2012-06-30 | $481,030 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2012-06-30 | $94,994 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2012-06-30 | $45,263 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-06-30 | No |
| Value of net income/loss | 2012-06-30 | $-49,731 |
| Value of net assets at end of year (total assets less liabilities) | 2012-06-30 | $-94,994 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-06-30 | $-45,263 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-06-30 | No |
| Contributions received in cash from employer | 2012-06-30 | $1,189,007 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-06-30 | $1,362,218 |
| Contract administrator fees | 2012-06-30 | $357,550 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2012-06-30 | No |
| Did the plan have assets held for investment | 2012-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-06-30 | Unqualified |
| Accountancy firm name | 2012-06-30 | HONKAMP KRUEGER & CO., P.C. |
| Accountancy firm EIN | 2012-06-30 | 420946155 |
| 2011 : RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2011 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-06-30 | $45,263 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-06-30 | $68,967 |
| Total income from all sources (including contributions) | 2011-06-30 | $1,986,005 |
| Total of all expenses incurred | 2011-06-30 | $1,962,301 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-06-30 | $1,609,507 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-06-30 | $1,986,005 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-06-30 | $352,794 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-06-30 | No |
| Was this plan covered by a fidelity bond | 2011-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2011-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-06-30 | No |
| Contributions received from participants | 2011-06-30 | $448,617 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2011-06-30 | $45,263 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2011-06-30 | $68,967 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-06-30 | No |
| Value of net income/loss | 2011-06-30 | $23,704 |
| Value of net assets at end of year (total assets less liabilities) | 2011-06-30 | $-45,263 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-06-30 | $-68,967 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-06-30 | No |
| Contributions received in cash from employer | 2011-06-30 | $1,537,388 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-06-30 | $1,609,507 |
| Contract administrator fees | 2011-06-30 | $352,794 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2011-06-30 | No |
| Did the plan have assets held for investment | 2011-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-06-30 | Unqualified |
| Accountancy firm name | 2011-06-30 | HONKAMP KRUEGER & CO., P.C. |
| Accountancy firm EIN | 2011-06-30 | 420946155 |
| 2016: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | This submission is the final filing | Yes |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2010 form 5500 responses |
|---|
| 2010-07-01 | Type of plan entity | Single employer plan |
| 2010-07-01 | Plan funding arrangement – Insurance | Yes |
| 2010-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: RIVERSIDE CASINO AND GOLF RESORT HEALTH CARE PLAN 2007 form 5500 responses |
|---|
| 2007-07-01 | Type of plan entity | Single employer plan |
| 2007-07-01 | First time form 5500 has been submitted | Yes |
| 2007-07-01 | This submission is the final filing | No |
| 2007-07-01 | Plan funding arrangement – Insurance | Yes |
| 2007-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2007-07-01 | Plan benefit arrangement – Insurance | Yes |
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 417004411562 |
| Policy instance | 1 |
| Insurance contract or identification number | 417004411562 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-07-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $51,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230776 |
| Policy instance | 3 |
| Insurance contract or identification number | 230776 | | Number of Individuals Covered | 496 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $31,831 | | Total amount of fees paid to insurance company | USD $2,653 | | Welfare Benefit Premiums Paid to Carrier | USD $414,226 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,221 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1972 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | UNITED BENEFITS ADVISORS INC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 417006411562 |
| Policy instance | 2 |
| Insurance contract or identification number | 417006411562 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-07-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $267,978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230776 |
| Policy instance | 3 |
| Insurance contract or identification number | 230776 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $30,699 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $353,998 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,466 | | Insurance broker organization code? | 3 | | Insurance broker name | STOP LOSS COALITION SERVICES LLC |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 417004411562 |
| Policy instance | 1 |
| Insurance contract or identification number | 417004411562 | | Number of Individuals Covered | 330 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $56,101 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 417006411562 |
| Policy instance | 2 |
| Insurance contract or identification number | 417006411562 | | Number of Individuals Covered | 330 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $230,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 20100 |
| Policy instance | 3 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $19,768 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $140,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,768 | | Insurance broker organization code? | 4 | | 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 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Insurance broker name | LARRY VOGT |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 20100 |
| Policy instance | 2 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $2,345 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $23,485 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,345 | | Insurance broker organization code? | 4 | | Insurance broker name | LARRY VOGT |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 20100 |
| Policy instance | 1 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $-25 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $-185 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $-25 | | Insurance broker organization code? | 4 | | Insurance broker name | LARRY VOGT |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230776 |
| Policy instance | 4 |
| Insurance contract or identification number | 230776 | | Number of Individuals Covered | 454 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $18,393 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $310,752 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,262 | | Insurance broker organization code? | 3 | | Insurance broker name | STOP LOSS COALITION SERVICES LLC |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 20100 |
| Policy instance | 1 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $38,522 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $280,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,522 | | Insurance broker organization code? | 3 | | Insurance broker name | LARRY VOGT |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 20100 |
| Policy instance | 2 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $4,251 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $42,575 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,251 | | Insurance broker organization code? | 3 | | Insurance broker name | LARRY VOGT |
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| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 20100 |
| Policy instance | 1 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $37,067 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $247,244 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 20100 |
| Policy instance | 2 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $3,510 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ORGAN TRANSPLANTS | | Welfare Benefit Premiums Paid to Carrier | USD $35,032 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 6002 |
| Policy instance | 1 |
| Insurance contract or identification number | 6002 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $24,226 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $242,166 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 20100 |
| Policy instance | 2 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $3,210 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ORGAN TRANSPLANTS | | Welfare Benefit Premiums Paid to Carrier | USD $32,109 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 20100 |
| Policy instance | 3 |
| Insurance contract or identification number | 20100 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $-123 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $-1,231 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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