LULUS FASHION LOUNGE HOLDINGS INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LULUS FASHION LOUNGE HEALTH & WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 467 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 466 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 466 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 350 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 320 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 320 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 791 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 505 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 505 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 647 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 791 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 791 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 560 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 581 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 581 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 308 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 583 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 14 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 2 |
| Total of all active and inactive participants | 2017-12-01 | 599 |
| Number of employers contributing to the scheme | 2017-12-01 | 0 |
| Total participants, beginning-of-year | 2017-06-01 | 308 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 583 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 14 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 2 |
| Total of all active and inactive participants | 2017-06-01 | 599 |
| 2022: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: LULUS FASHION LOUNGE HEALTH & WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | First time form 5500 has been submitted | Yes |
| 2017-12-01 | Submission has been amended | Yes |
| 2017-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-06-01 | Type of plan entity | Single employer plan |
| 2017-06-01 | First time form 5500 has been submitted | Yes |
| 2017-06-01 | Submission has been amended | No |
| 2017-06-01 | This submission is the final filing | No |
| 2017-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-06-01 | Plan is a collectively bargained plan | No |
| 2017-06-01 | Plan funding arrangement – Insurance | Yes |
| 2017-06-01 | Plan benefit arrangement – Insurance | Yes |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 952154 |
| Policy instance | 3 |
| Insurance contract or identification number | 952154 | | Number of Individuals Covered | 761 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $20,786 | | Total amount of fees paid to insurance company | USD $2,543 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $145,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,786 | | Amount paid for insurance broker fees | 2543 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 281541 |
| Policy instance | 2 |
| Insurance contract or identification number | 281541 | | Number of Individuals Covered | 765 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $12,481 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,186 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,481 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 878024 |
| Policy instance | 1 |
| Insurance contract or identification number | 878024 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,493 | | Total amount of fees paid to insurance company | USD $544 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $20,021 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,493 | | Amount paid for insurance broker fees | 544 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 952154 |
| Policy instance | 4 |
| Insurance contract or identification number | 952154 | | Number of Individuals Covered | 666 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $14,536 | | Total amount of fees paid to insurance company | USD $1,700 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $102,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,970 | | Amount paid for insurance broker fees | 1656 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 878024 |
| Policy instance | 3 |
| Insurance contract or identification number | 878024 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $8,879 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 11685263 |
| Policy instance | 2 |
| Insurance contract or identification number | 11685263 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $24 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $484 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 281541 |
| Policy instance | 1 |
| Insurance contract or identification number | 281541 | | Number of Individuals Covered | 695 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $115,286 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,182,854 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $115,286 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 281541 |
| Policy instance | 1 |
| Insurance contract or identification number | 281541 | | Number of Individuals Covered | 528 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $124,285 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,200,376 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $124,285 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0716043 |
| Policy instance | 2 |
| Insurance contract or identification number | R0716043 | | Number of Individuals Covered | 272 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,399 | | Total amount of fees paid to insurance company | USD $293 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $-7,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,685 | | Amount paid for insurance broker fees | 293 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 11685263 |
| Policy instance | 3 |
| Insurance contract or identification number | 11685263 | | Number of Individuals Covered | 372 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $-5,833 | | Total amount of fees paid to insurance company | USD $-118 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $-56,363 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $-1,751 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 952154 |
| Policy instance | 4 |
| Insurance contract or identification number | 952154 | | Number of Individuals Covered | 505 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,561 | | Total amount of fees paid to insurance company | USD $711 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $40,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,561 | | Amount paid for insurance broker fees | 711 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | M4137279 |
| Policy instance | 1 |
| Insurance contract or identification number | M4137279 | | Number of Individuals Covered | 598 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,883 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $279,211 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,883 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 281541 |
| Policy instance | 2 |
| Insurance contract or identification number | 281541 | | Number of Individuals Covered | 725 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $127,440 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,810,722 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $127,440 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 11685263 |
| Policy instance | 3 |
| Insurance contract or identification number | 11685263 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $27,676 | | Total amount of fees paid to insurance company | USD $873 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $155,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,377 | | Amount paid for insurance broker fees | 873 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 952154 |
| Policy instance | 4 |
| Insurance contract or identification number | 952154 | | Number of Individuals Covered | 754 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $12,848 | | Total amount of fees paid to insurance company | USD $1,029 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $81,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,005 | | Amount paid for insurance broker fees | 756 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 952154 |
| Policy instance | 4 |
| Insurance contract or identification number | 952154 | | Number of Individuals Covered | 539 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $686 | | Total amount of fees paid to insurance company | USD $87 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 292-083 |
| Policy instance | 3 |
| Insurance contract or identification number | 292-083 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $686 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280671 |
| Policy instance | 2 |
| Insurance contract or identification number | 280671 | | Number of Individuals Covered | 566 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $19,719 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $249,678 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | M41-37279 |
| Policy instance | 1 |
| Insurance contract or identification number | M41-37279 | | Number of Individuals Covered | 391 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,654 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,541 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | M41-37279 |
| Policy instance | 2 |
| Insurance contract or identification number | M41-37279 | | Number of Individuals Covered | 391 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,654 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $56,541 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,654 | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INSURANCE SERVICES, LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 952154 |
| Policy instance | 3 |
| Insurance contract or identification number | 952154 | | Number of Individuals Covered | 549 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $2,082 | | Total amount of fees paid to insurance company | USD $324 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&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 Carrier | USD $13,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,082 | | Amount paid for insurance broker fees | 324 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INSURANCE SERVICES |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280671 |
| Policy instance | 4 |
| Insurance contract or identification number | 280671 | | Number of Individuals Covered | 563 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $44,307 | | Total amount of fees paid to insurance company | USD $2,188 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,211,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,307 | | Amount paid for insurance broker fees | 4 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INSURANCE SERV, INC |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 292-083 |
| Policy instance | 5 |
| Insurance contract or identification number | 292-083 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $1,914 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $28,713 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,914 | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INS SERVICES LLC |
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| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 292-083 |
| Policy instance | 6 |
| Insurance contract or identification number | 292-083 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $686 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $5,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $686 | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INS SERVICES, LLC |
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| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280671 |
| Policy instance | 7 |
| Insurance contract or identification number | 280671 | | Number of Individuals Covered | 566 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $19,719 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $249,678 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,719 | | Amount paid for insurance broker fees | 2184 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INSURANCE SERV, INC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 952155 |
| Policy instance | 8 |
| Insurance contract or identification number | 952155 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $1,565 | | Total amount of fees paid to insurance company | USD $216 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LIFESTYLE AD&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 Carrier | USD $9,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,565 | | Amount paid for insurance broker fees | 216 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INSURANCE SERVICES I |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 951254 |
| Policy instance | 9 |
| Insurance contract or identification number | 951254 | | Number of Individuals Covered | 539 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $421 | | Total amount of fees paid to insurance company | USD $65 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&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 Carrier | USD $3,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $421 | | Amount paid for insurance broker fees | 65 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INSURANCE SERVICES I |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 952155 |
| Policy instance | 1 |
| Insurance contract or identification number | 952155 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $265 | | Total amount of fees paid to insurance company | USD $22 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LIFESTYLE AD&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 Carrier | USD $1,764 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $265 | | Amount paid for insurance broker fees | 22 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST INSURANCE SERVICES I |
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