EMPIRE INTERNATIONAL, LTD. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN
Measure | Date | Value |
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2022: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-07-01 | 433 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 516 |
Number of retired or separated participants receiving benefits | 2022-07-01 | 4 |
Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
Total of all active and inactive participants | 2022-07-01 | 520 |
2021: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-07-01 | 180 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 431 |
Number of retired or separated participants receiving benefits | 2021-07-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
Total of all active and inactive participants | 2021-07-01 | 433 |
Total participants | 2021-07-01 | 433 |
2020: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 129 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 180 |
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 | 180 |
Total participants | 2020-01-01 | 180 |
2019: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 642 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 109 |
Number of retired or separated participants receiving benefits | 2019-01-01 | 20 |
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 | 129 |
Total participants | 2019-01-01 | 129 |
2018: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-07-01 | 591 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 641 |
Number of retired or separated participants receiving benefits | 2018-07-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
Total of all active and inactive participants | 2018-07-01 | 642 |
Total participants | 2018-07-01 | 642 |
2017: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-07-01 | 600 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 589 |
Number of retired or separated participants receiving benefits | 2017-07-01 | 2 |
Total of all active and inactive participants | 2017-07-01 | 591 |
Total participants | 2017-07-01 | 591 |
2016: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-07-01 | 603 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 598 |
Number of retired or separated participants receiving benefits | 2016-07-01 | 2 |
Total of all active and inactive participants | 2016-07-01 | 600 |
Total participants | 2016-07-01 | 600 |
2015: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-07-01 | 588 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 595 |
Number of retired or separated participants receiving benefits | 2015-07-01 | 8 |
Total of all active and inactive participants | 2015-07-01 | 603 |
Total participants | 2015-07-01 | 603 |
2014: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-07-01 | 582 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 582 |
Number of retired or separated participants receiving benefits | 2014-07-01 | 6 |
Total of all active and inactive participants | 2014-07-01 | 588 |
Total participants | 2014-07-01 | 588 |
2013: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-07-01 | 546 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 573 |
Number of retired or separated participants receiving benefits | 2013-07-01 | 9 |
Total of all active and inactive participants | 2013-07-01 | 582 |
Total participants | 2013-07-01 | 582 |
2012: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-07-01 | 542 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 543 |
Number of retired or separated participants receiving benefits | 2012-07-01 | 3 |
Total of all active and inactive participants | 2012-07-01 | 546 |
Total participants | 2012-07-01 | 546 |
2011: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-07-01 | 531 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 536 |
Number of retired or separated participants receiving benefits | 2011-07-01 | 6 |
Total of all active and inactive participants | 2011-07-01 | 542 |
Total participants | 2011-07-01 | 542 |
2010: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2010 401k membership |
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Total participants, beginning-of-year | 2010-07-01 | 547 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-07-01 | 525 |
Number of retired or separated participants receiving benefits | 2010-07-01 | 6 |
Total of all active and inactive participants | 2010-07-01 | 531 |
Total participants | 2010-07-01 | 531 |
2009: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-07-01 | 541 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 530 |
Number of retired or separated participants receiving benefits | 2009-07-01 | 17 |
Total of all active and inactive participants | 2009-07-01 | 547 |
Total participants | 2009-07-01 | 547 |
2022: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2022 form 5500 responses |
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2022-07-01 | Type of plan entity | Single employer plan |
2022-07-01 | Submission has been amended | No |
2022-07-01 | This submission is the final filing | No |
2022-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-07-01 | Plan is a collectively bargained plan | No |
2022-07-01 | Plan funding arrangement – Insurance | Yes |
2022-07-01 | Plan benefit arrangement – Insurance | Yes |
2021: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2021 form 5500 responses |
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2021-07-01 | Type of plan entity | Single employer plan |
2021-07-01 | Submission has been amended | No |
2021-07-01 | This submission is the final filing | No |
2021-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-07-01 | Plan is a collectively bargained plan | No |
2021-07-01 | Plan funding arrangement – Insurance | Yes |
2021-07-01 | Plan benefit arrangement – Insurance | Yes |
2020: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2020 form 5500 responses |
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2020-01-01 | Type of plan entity | Single employer plan |
2020-01-01 | Submission has been amended | No |
2020-01-01 | This submission is the final filing | No |
2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-01-01 | Plan is a collectively bargained plan | No |
2020-01-01 | Plan funding arrangement – Insurance | Yes |
2020-01-01 | Plan benefit arrangement – Insurance | Yes |
2019: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2019 form 5500 responses |
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2019-01-01 | Type of plan entity | Single employer plan |
2019-01-01 | Submission has been amended | No |
2019-01-01 | This submission is the final filing | No |
2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-01-01 | Plan is a collectively bargained plan | No |
2019-01-01 | Plan funding arrangement – Insurance | Yes |
2019-01-01 | Plan benefit arrangement – Insurance | Yes |
2018: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2018 form 5500 responses |
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2018-07-01 | Type of plan entity | Single employer plan |
2018-07-01 | Submission has been amended | No |
2018-07-01 | This submission is the final filing | No |
2018-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-07-01 | Plan is a collectively bargained plan | No |
2018-07-01 | Plan funding arrangement – Insurance | Yes |
2018-07-01 | Plan benefit arrangement – Insurance | Yes |
2017: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2017 form 5500 responses |
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2017-07-01 | Type of plan entity | Single employer plan |
2017-07-01 | Submission has been amended | No |
2017-07-01 | This submission is the final filing | No |
2017-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-07-01 | Plan is a collectively bargained plan | No |
2017-07-01 | Plan funding arrangement – Insurance | Yes |
2017-07-01 | Plan benefit arrangement – Insurance | Yes |
2016: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2016 form 5500 responses |
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2016-07-01 | Type of plan entity | Single employer plan |
2016-07-01 | Submission has been amended | No |
2016-07-01 | This submission is the final filing | No |
2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-07-01 | Plan is a collectively bargained plan | No |
2016-07-01 | Plan funding arrangement – Insurance | Yes |
2016-07-01 | Plan benefit arrangement – Insurance | Yes |
2015: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2015 form 5500 responses |
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2015-07-01 | Type of plan entity | Single employer plan |
2015-07-01 | Submission has been amended | No |
2015-07-01 | This submission is the final filing | No |
2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-07-01 | Plan is a collectively bargained plan | No |
2015-07-01 | Plan funding arrangement – Insurance | Yes |
2015-07-01 | Plan benefit arrangement – Insurance | Yes |
2014: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2014 form 5500 responses |
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2014-07-01 | Type of plan entity | Single employer plan |
2014-07-01 | Submission has been amended | No |
2014-07-01 | This submission is the final filing | No |
2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-07-01 | Plan is a collectively bargained plan | No |
2014-07-01 | Plan funding arrangement – Insurance | Yes |
2014-07-01 | Plan benefit arrangement – Insurance | Yes |
2013: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2013 form 5500 responses |
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2013-07-01 | Type of plan entity | Single employer plan |
2013-07-01 | Submission has been amended | No |
2013-07-01 | This submission is the final filing | No |
2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-07-01 | Plan is a collectively bargained plan | No |
2013-07-01 | Plan funding arrangement – Insurance | Yes |
2013-07-01 | Plan benefit arrangement – Insurance | Yes |
2012: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2012 form 5500 responses |
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2012-07-01 | Type of plan entity | Single employer plan |
2012-07-01 | Submission has been amended | No |
2012-07-01 | This submission is the final filing | No |
2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-07-01 | Plan is a collectively bargained plan | No |
2012-07-01 | Plan funding arrangement – Insurance | Yes |
2012-07-01 | Plan benefit arrangement – Insurance | Yes |
2011: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2011 form 5500 responses |
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2011-07-01 | Type of plan entity | Single employer plan |
2011-07-01 | Submission has been amended | No |
2011-07-01 | This submission is the final filing | No |
2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-07-01 | Plan is a collectively bargained plan | No |
2011-07-01 | Plan funding arrangement – Insurance | Yes |
2011-07-01 | Plan benefit arrangement – Insurance | Yes |
2010: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2010 form 5500 responses |
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2010-07-01 | Type of plan entity | Single employer plan |
2010-07-01 | Submission has been amended | No |
2010-07-01 | This submission is the final filing | No |
2010-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2010-07-01 | Plan is a collectively bargained plan | No |
2010-07-01 | Plan funding arrangement – Insurance | Yes |
2010-07-01 | Plan benefit arrangement – Insurance | Yes |
2009: EMPIRE INTERNATIONAL HEALTH AND WELFARE PLAN 2009 form 5500 responses |
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2009-07-01 | Type of plan entity | Single employer plan |
2009-07-01 | Submission has been amended | No |
2009-07-01 | This submission is the final filing | No |
2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-07-01 | Plan is a collectively bargained plan | No |
2009-07-01 | Plan funding arrangement – Insurance | Yes |
2009-07-01 | Plan benefit arrangement – Insurance | Yes |
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 5 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 516 | Insurance policy start date | 2022-07-01 | Insurance policy end date | 2023-06-30 | Total amount of commissions paid to insurance broker | USD $5,002 | Total amount of fees paid to insurance company | USD $3,067 | 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 | 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 $50,019 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,002 | Amount paid for insurance broker fees | 2538 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 4 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 6 | Insurance policy start date | 2022-07-01 | Insurance policy end date | 2023-06-30 | Total amount of commissions paid to insurance broker | USD $981 | Total amount of fees paid to insurance company | USD $825 | 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 | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | 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 $9,810 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $981 | Amount paid for insurance broker fees | 683 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 234505 |
Policy instance | 3 |
Insurance contract or identification number | 234505 | Number of Individuals Covered | 76 | Insurance policy start date | 2022-07-01 | Insurance policy end date | 2023-06-30 | Total amount of commissions paid to insurance broker | USD $12,699 | 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 | 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 $418,038 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,699 | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0308565 |
Policy instance | 2 |
Insurance contract or identification number | 0308565 | Number of Individuals Covered | 348 | Insurance policy start date | 2022-07-01 | Insurance policy end date | 2023-06-30 | Total amount of commissions paid to insurance broker | USD $10,734 | 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 | 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 $2,513,463 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,734 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 12289141 |
Policy instance | 1 |
Insurance contract or identification number | 12289141 | Number of Individuals Covered | 189 | Insurance policy start date | 2022-07-01 | Insurance policy end date | 2023-06-30 | Total amount of commissions paid to insurance broker | USD $1,206 | 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 $23,477 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,206 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 12289141 |
Policy instance | 1 |
Insurance contract or identification number | 12289141 | Number of Individuals Covered | 149 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-06-30 | Total amount of commissions paid to insurance broker | USD $980 | 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 $16,847 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $980 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0308565 |
Policy instance | 2 |
Insurance contract or identification number | 0308565 | Number of Individuals Covered | 273 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-06-30 | Total amount of commissions paid to insurance broker | USD $6,880 | 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 | 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 $1,639,356 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,880 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 234505 |
Policy instance | 3 |
Insurance contract or identification number | 234505 | Number of Individuals Covered | 54 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-06-30 | Total amount of commissions paid to insurance broker | USD $9,524 | 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 | 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 $327,962 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,524 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 4 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 6 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-07-01 | Total amount of commissions paid to insurance broker | USD $1,264 | Total amount of fees paid to insurance company | USD $940 | 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 | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | 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 $12,691 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 162 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 5 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 431 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-07-01 | Total amount of commissions paid to insurance broker | USD $3,332 | Total amount of fees paid to insurance company | USD $1,506 | 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 | 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 $33,545 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 260 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 234505 |
Policy instance | 5 |
Insurance contract or identification number | 234505 | Number of Individuals Covered | 45 | Insurance policy start date | 2020-07-01 | Insurance policy end date | 2021-06-30 | Total amount of commissions paid to insurance broker | USD $8,383 | 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 | 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 $251,788 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,383 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 4 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 180 | Insurance policy start date | 2020-07-01 | Insurance policy end date | 2021-07-01 | Total amount of commissions paid to insurance broker | USD $1,621 | Total amount of fees paid to insurance company | USD $1,256 | 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 | 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 $16,214 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 369 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 3 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 8 | Insurance policy start date | 2020-07-01 | Insurance policy end date | 2021-07-01 | Total amount of commissions paid to insurance broker | USD $1,296 | Total amount of fees paid to insurance company | USD $551 | 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 | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | 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 $12,960 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 162 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0308565 |
Policy instance | 2 |
Insurance contract or identification number | 0308565 | Number of Individuals Covered | 222 | Insurance policy start date | 2020-07-01 | Insurance policy end date | 2021-06-30 | Total amount of commissions paid to insurance broker | USD $6,870 | 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 | 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 $983,468 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,870 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 12289141 |
Policy instance | 1 |
Insurance contract or identification number | 12289141 | Number of Individuals Covered | 118 | Insurance policy start date | 2020-07-01 | Insurance policy end date | 2021-06-30 | Total amount of commissions paid to insurance broker | USD $849 | 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 $13,205 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $849 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 12289141 |
Policy instance | 1 |
Insurance contract or identification number | 12289141 | Number of Individuals Covered | 93 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $1,399 | 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 $30,936 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,399 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0308565 |
Policy instance | 2 |
Insurance contract or identification number | 0308565 | Number of Individuals Covered | 174 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $13,054 | 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 | 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 $2,147,518 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,239 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 606395 |
Policy instance | 3 |
Insurance contract or identification number | 606395 | Number of Individuals Covered | 0 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $160 | Total amount of fees paid to insurance company | USD $5,027 | 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 | 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 $5,346 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $160 | Amount paid for insurance broker fees | 5027 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 234505 |
Policy instance | 4 |
Insurance contract or identification number | 234505 | Number of Individuals Covered | 38 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $17,924 | Total amount of fees paid to insurance company | USD $9,996 | 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 | 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 $625,131 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,924 | Amount paid for insurance broker fees | 9996 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 2 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 5 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 8 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $1,296 | Total amount of fees paid to insurance company | USD $551 | 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 | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | 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 $12,960 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 162 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 6 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 107 | Insurance policy start date | 2019-07-01 | Insurance policy end date | 2020-06-30 | Total amount of commissions paid to insurance broker | USD $4,812 | Total amount of fees paid to insurance company | USD $2,520 | 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 | 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 $48,116 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 741 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 4 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 670 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-07-01 | Total amount of commissions paid to insurance broker | USD $5,886 | 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 | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $58,860 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $495 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BCTW |
Policy instance | 3 |
Insurance contract or identification number | G000BCTW | Number of Individuals Covered | 8 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-07-01 | Total amount of commissions paid to insurance broker | USD $1,296 | 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 | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | 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 $12,960 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $108 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 12289141 |
Policy instance | 2 |
Insurance contract or identification number | 12289141 | Number of Individuals Covered | 314 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-06-30 | Total amount of commissions paid to insurance broker | USD $1,570 | 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 $37,097 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $69 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0308565 |
Policy instance | 1 |
Insurance contract or identification number | 0308565 | Number of Individuals Covered | 571 | Insurance policy start date | 2018-07-01 | Insurance policy end date | 2019-06-30 | Total amount of commissions paid to insurance broker | USD $15,702 | 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 | 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 $3,553,124 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,702 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 12289141 |
Policy instance | 2 |
Insurance contract or identification number | 12289141 | Number of Individuals Covered | 307 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2018-06-30 | Total amount of commissions paid to insurance broker | USD $1,432 | 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 $31,135 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,432 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | VERTICAL FOX LLC |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0308565 |
Policy instance | 1 |
Insurance contract or identification number | 0308565 | Number of Individuals Covered | 568 | Insurance policy start date | 2017-07-01 | Insurance policy end date | 2018-06-30 | Total amount of commissions paid to insurance broker | USD $21,120 | 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 | Yes | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,897,133 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $21,120 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | VERTICAL FOX LLC |
|