ROSS TECHNOLOGY COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN
401k plan membership statisitcs for ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN
| Measure | Date | Value |
|---|
| 2021: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 135 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 67 |
| 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 | 67 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 135 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 110 |
| 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 | 110 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 135 |
| 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 | 135 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 135 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 152 |
| 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 | 152 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 133 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 133 |
| 2016: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 139 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 139 |
| 2015: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 114 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 114 |
| 2014: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 113 |
| Total of all active and inactive participants | 2014-01-01 | 113 |
| 2013: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 112 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 112 |
| 2012: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 118 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 118 |
| 2011: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 121 |
| Total of all active and inactive participants | 2011-01-01 | 121 |
| 2010: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 118 |
| Total of all active and inactive participants | 2010-01-01 | 118 |
| 2009: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 120 |
| Total of all active and inactive participants | 2009-01-01 | 120 |
| 2008: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-01-01 | 122 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-01-01 | 120 |
| Total of all active and inactive participants | 2008-01-01 | 120 |
| 2007: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-01-01 | 136 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-01-01 | 122 |
| Total of all active and inactive participants | 2007-01-01 | 122 |
| 2006: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2006 401k membership |
|---|
| Total participants, beginning-of-year | 2006-01-01 | 126 |
| Total number of active participants reported on line 7a of the Form 5500 | 2006-01-01 | 136 |
| Total of all active and inactive participants | 2006-01-01 | 136 |
| 2005: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2005 401k membership |
|---|
| Total participants, beginning-of-year | 2005-01-01 | 143 |
| Total number of active participants reported on line 7a of the Form 5500 | 2005-01-01 | 126 |
| Total of all active and inactive participants | 2005-01-01 | 126 |
| 2004: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2004 401k membership |
|---|
| Total participants, beginning-of-year | 2004-01-01 | 143 |
| Total number of active participants reported on line 7a of the Form 5500 | 2004-01-01 | 143 |
| Total of all active and inactive participants | 2004-01-01 | 143 |
| 2021: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE 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 benefit arrangement – Insurance | Yes |
| 2020: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE 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: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | Yes |
| 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: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | Yes |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2008 form 5500 responses |
|---|
| 2008-01-01 | Type of plan entity | Single employer plan |
| 2008-01-01 | Plan funding arrangement – Insurance | Yes |
| 2008-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2007 form 5500 responses |
|---|
| 2007-01-01 | Type of plan entity | Single employer plan |
| 2007-01-01 | Plan funding arrangement – Insurance | Yes |
| 2007-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2006: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2006 form 5500 responses |
|---|
| 2006-01-01 | Type of plan entity | Single employer plan |
| 2006-01-01 | Plan funding arrangement – Insurance | Yes |
| 2006-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2005: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2005 form 5500 responses |
|---|
| 2005-01-01 | Type of plan entity | Single employer plan |
| 2005-01-01 | Plan funding arrangement – Insurance | Yes |
| 2005-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2004: ROSS TECHNOLOGIES CORPORATION HEALTH INSURANCE PLAN 2004 form 5500 responses |
|---|
| 2004-01-01 | Type of plan entity | Single employer plan |
| 2004-01-01 | Plan funding arrangement – Insurance | Yes |
| 2004-01-01 | Plan benefit arrangement – Insurance | Yes |
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 702387 |
| Policy instance | 3 |
| Insurance contract or identification number | 702387 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $431 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $431 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 516366 |
| Policy instance | 2 |
| Insurance contract or identification number | 516366 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $8,297 | | Total amount of fees paid to insurance company | USD $208 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $76,316 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,297 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 907796-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 907796-099 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $5,786 | | Total amount of fees paid to insurance company | USD $2,049 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,643 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,816 | | Amount paid for insurance broker fees | 2049 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 516366 |
| Policy instance | 2 |
| Insurance contract or identification number | 516366 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $7,330 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $67,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,921 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 907796-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 907796-099 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,180 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $57,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,707 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 907796-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 907796-099 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $6,620 | | Total amount of fees paid to insurance company | USD $2,588 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $65,567 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,620 | | Amount paid for insurance broker fees | 2588 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 516366 |
| Policy instance | 2 |
| Insurance contract or identification number | 516366 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $7,807 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $72,863 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,807 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 516366 |
| Policy instance | 3 |
| Insurance contract or identification number | 516366 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,469 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $19,733 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,469 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 516366 |
| Policy instance | 4 |
| Insurance contract or identification number | 516366 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,469 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $19,733 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,469 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 504381 |
| Policy instance | 3 |
| Insurance contract or identification number | 504381 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $29,920 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,826,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,920 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00516366 |
| Policy instance | 2 |
| Insurance contract or identification number | 00516366 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $8,533 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $84,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,533 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 907796-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 907796-099 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $7,718 | | Total amount of fees paid to insurance company | USD $2,955 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,718 | | Amount paid for insurance broker fees | 2955 | | Additional information about fees paid to insurance broker | NON MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 907796-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 907796-099 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,605 | | Total amount of fees paid to insurance company | USD $2,116 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,979 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,605 | | Amount paid for insurance broker fees | 2116 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | ERC OF NY, INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00516366 |
| Policy instance | 2 |
| Insurance contract or identification number | 00516366 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-10-31 | | Total amount of commissions paid to insurance broker | USD $8,197 | | Total amount of fees paid to insurance company | USD $4,420 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $78,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,197 | | Amount paid for insurance broker fees | 4420 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LACHER & ASSOICIATES INSURANCE |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 504381 |
| Policy instance | 3 |
| Insurance contract or identification number | 504381 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $29,200 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,200 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LACHER AND ASSOCIATES |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 504381 |
| Policy instance | 3 |
| Insurance contract or identification number | 504381 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,000 | | Insurance broker organization code? | 3 | | Insurance broker name | LACHER AND ASSOCIATES INS. AGENCY |
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| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F012706 |
| Policy instance | 2 |
| Insurance contract or identification number | F012706 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $8,016 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,075 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,289 | | Insurance broker organization code? | 3 | | Insurance broker name | FIFS LLC |
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| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 907796-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 907796-099 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,789 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $53,928 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,789 | | Insurance broker organization code? | 3 | | Insurance broker name | EMERSON REID AND COMPANY, INC. |
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| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $20,000 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,000 | | Insurance broker organization code? | 3 | | Insurance broker name | LACHER & ASSOCIATES |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F012706 |
| Policy instance | 2 |
| Insurance contract or identification number | F012706 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $8,568 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $65,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,568 | | Insurance broker organization code? | 3 | | Insurance broker name | LACHER & ASSOCIATES |
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| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $20,000 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 2 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 2 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $20,000 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,000 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCHER & ASSOCIATES |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-12-31 | | Total amount of commissions paid to insurance broker | USD $39,523 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,523 | | Insurance broker organization code? | 3 | | Insurance broker name | HRH METRO NORTHEAST LLC |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 2 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 2 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $35,045 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,045 | | Insurance broker organization code? | 3 | | Insurance broker name | HRH METRO NORTHEAST LLC |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2007-01-01 | | Insurance policy end date | 2007-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 2 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2007-01-01 | | Insurance policy end date | 2007-12-31 | | Total amount of commissions paid to insurance broker | USD $32,071 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,071 | | Insurance broker organization code? | 3 | | Insurance broker name | BANC OF AMERICA CORPORATE INSURANCE |
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| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 2 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2006-01-01 | | Insurance policy end date | 2006-12-31 | | Total amount of commissions paid to insurance broker | USD $8,587 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,587 | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE DYNAMICS |
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| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00504381 |
| Policy instance | 3 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2006-01-01 | | Insurance policy end date | 2006-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $104,282 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| CAPITAL BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54720 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2006-01-01 | | Insurance policy end date | 2006-12-31 | | Total amount of commissions paid to insurance broker | USD $1,697 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,697 | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE DYNAMICS |
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| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 2 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2005-01-01 | | Insurance policy end date | 2005-12-31 | | Total amount of commissions paid to insurance broker | USD $12,682 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,715 | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE DYNAMICS |
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| CAPITAL BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54720 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2005-01-01 | | Insurance policy end date | 2005-12-31 | | Total amount of commissions paid to insurance broker | USD $2,635 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,811 | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE DYNAMICS |
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| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00504381 |
| Policy instance | 2 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2004-01-01 | | Insurance policy end date | 2004-12-31 | | Total amount of commissions paid to insurance broker | USD $9,716 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,716 | | Insurance broker organization code? | 3 | | Insurance broker name | UNIVERSAL BENEFITS GROUP |
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| CAPITAL BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54720 ) |
| Policy contract number | 00504381 |
| Policy instance | 1 |
| Insurance contract or identification number | 00504381 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2004-01-01 | | Insurance policy end date | 2004-12-31 | | Total amount of commissions paid to insurance broker | USD $2,175 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,175 | | Insurance broker organization code? | 3 | | Insurance broker name | UNIVERSAL BENEFITS GROUP |
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