MARTY SUSSMAN ORGANIZATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN
401k plan membership statisitcs for MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-01 | 169 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 0 |
| Number of retired or separated participants receiving benefits | 2022-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
| Total of all active and inactive participants | 2022-06-01 | 0 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2022-06-01 | 0 |
| Total participants | 2022-06-01 | 0 |
| Number of participants with account balances | 2022-06-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2022-06-01 | 0 |
| 2021: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-06-01 | 169 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 165 |
| Number of retired or separated participants receiving benefits | 2021-06-01 | 4 |
| Total of all active and inactive participants | 2021-06-01 | 169 |
| Total participants | 2021-06-01 | 169 |
| 2020: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-06-01 | 189 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 168 |
| Number of retired or separated participants receiving benefits | 2020-06-01 | 1 |
| Total of all active and inactive participants | 2020-06-01 | 169 |
| Total participants | 2020-06-01 | 169 |
| 2019: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-06-01 | 190 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 188 |
| Number of retired or separated participants receiving benefits | 2019-06-01 | 1 |
| Total of all active and inactive participants | 2019-06-01 | 189 |
| Total participants | 2019-06-01 | 189 |
| 2018: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 190 |
| Number of retired or separated participants receiving benefits | 2018-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
| Total of all active and inactive participants | 2018-06-01 | 190 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2018-06-01 | 0 |
| Total participants | 2018-06-01 | 190 |
| 2017: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-01 | 194 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 192 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 1 |
| Total of all active and inactive participants | 2017-06-01 | 193 |
| Total participants | 2017-06-01 | 193 |
| 2016: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 194 |
| Number of retired or separated participants receiving benefits | 2016-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 0 |
| Total of all active and inactive participants | 2016-06-01 | 194 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2016-06-01 | 0 |
| Total participants | 2016-06-01 | 194 |
| 2015: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 198 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 191 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 0 |
| Total of all active and inactive participants | 2015-06-01 | 193 |
| Total participants | 2015-06-01 | 193 |
| 2014: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 180 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 196 |
| Number of retired or separated participants receiving benefits | 2014-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 0 |
| Total of all active and inactive participants | 2014-06-01 | 198 |
| 2013: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 186 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 183 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
| Total of all active and inactive participants | 2013-06-01 | 185 |
| 2012: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-06-01 | 189 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 193 |
| Number of retired or separated participants receiving benefits | 2012-06-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 0 |
| Total of all active and inactive participants | 2012-06-01 | 196 |
| 2011: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-06-01 | 166 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-06-01 | 187 |
| Number of retired or separated participants receiving benefits | 2011-06-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2011-06-01 | 0 |
| Total of all active and inactive participants | 2011-06-01 | 191 |
| 2022: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | This submission is the final filing | Yes |
| 2022-06-01 | Plan funding arrangement – Insurance | Yes |
| 2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-06-01 | Type of plan entity | Single employer plan |
| 2021-06-01 | Plan funding arrangement – Insurance | Yes |
| 2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-06-01 | Type of plan entity | Single employer plan |
| 2020-06-01 | Plan funding arrangement – Insurance | Yes |
| 2020-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-06-01 | Type of plan entity | Single employer plan |
| 2019-06-01 | Plan funding arrangement – Insurance | Yes |
| 2019-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-06-01 | Type of plan entity | Single employer plan |
| 2018-06-01 | Plan funding arrangement – Insurance | Yes |
| 2018-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-06-01 | Type of plan entity | Single employer plan |
| 2017-06-01 | Plan funding arrangement – Insurance | Yes |
| 2017-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-06-01 | Type of plan entity | Single employer plan |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Single employer plan |
| 2014-06-01 | Submission has been amended | Yes |
| 2014-06-01 | This submission is the final filing | No |
| 2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-01 | Plan is a collectively bargained plan | No |
| 2014-06-01 | Plan funding arrangement – Insurance | Yes |
| 2014-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | Submission has been amended | Yes |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – Insurance | Yes |
| 2013-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-06-01 | Type of plan entity | Single employer plan |
| 2012-06-01 | Submission has been amended | Yes |
| 2012-06-01 | This submission is the final filing | No |
| 2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-06-01 | Plan is a collectively bargained plan | No |
| 2012-06-01 | Plan funding arrangement – Insurance | Yes |
| 2012-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: MARTY SUSSMAN ORGANIZATION SEC 125 FLEXIBLE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-06-01 | Type of plan entity | Single employer plan |
| 2011-06-01 | First time form 5500 has been submitted | Yes |
| 2011-06-01 | Submission has been amended | Yes |
| 2011-06-01 | This submission is the final filing | No |
| 2011-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-06-01 | Plan is a collectively bargained plan | No |
| 2011-06-01 | Plan funding arrangement – Insurance | Yes |
| 2011-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 1075227 |
| Policy instance | 3 |
| Insurance contract or identification number | 1075227 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $6,650 | | Health Insurance Welfare Benefit | Yes | | Commission paid to Insurance Broker | USD $1,729 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 010469 |
| Policy instance | 2 |
| Insurance contract or identification number | 010469 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-07-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $576 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 955164 |
| Policy instance | 1 |
| Insurance contract or identification number | 955164 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $1,470 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD, BASIC SHORT-TERM DISABILITY | | Commission paid to Insurance Broker | USD $988 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5993137 |
| Policy instance | 3 |
| Insurance contract or identification number | 5993137 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $6,494 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 010469 |
| Policy instance | 2 |
| Insurance contract or identification number | 010469 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $950 | | Total amount of fees paid to insurance company | USD $695 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,334 | | Commission paid to Insurance Broker | USD $950 | | Amount paid for insurance broker fees | 303 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0777579 |
| Policy instance | 1 |
| Insurance contract or identification number | 0777579 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5993137 |
| Policy instance | 2 |
| Insurance contract or identification number | 5993137 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $1,457 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $8,585 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,112 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0777579 |
| Policy instance | 1 |
| Insurance contract or identification number | 0777579 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0777579 |
| Policy instance | 1 |
| Insurance contract or identification number | 0777579 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2019-05-31 | | Health Insurance Welfare Benefit | Yes |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5993137 |
| Policy instance | 2 |
| Insurance contract or identification number | 5993137 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $1,521 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $9,063 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,158 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05993137 |
| Policy instance | 3 |
| Insurance contract or identification number | TS05993137 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $1,484 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD | | Welfare Benefit Premiums Paid to Carrier | USD $8,884 | | Commission paid to Insurance Broker | USD $1,058 | | Insurance broker organization code? | 3 | | Insurance broker name | ERIK BRONSTEIN |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 71740 |
| Policy instance | 2 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $53,235 | | 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 $53,235 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS INC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 71740 |
| Policy instance | 1 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $3,299 | | 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 $3,299 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS INC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 71740 |
| Policy instance | 1 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $3,726 | | Health Insurance Welfare Benefit | Yes | | Commission paid to Insurance Broker | USD $3,726 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 71740 |
| Policy instance | 2 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $51,612 | | 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 $51,612 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05993137 |
| Policy instance | 3 |
| Insurance contract or identification number | TS05993137 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $1,412 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD | | Welfare Benefit Premiums Paid to Carrier | USD $7,872 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,025 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05993137 |
| Policy instance | 3 |
| Insurance contract or identification number | TS05993137 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $1,174 | | 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 | 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 $6,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $866 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 71740 |
| Policy instance | 2 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $44,298 | | 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 $44,298 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 71740 |
| Policy instance | 1 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $4,922 | | 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 $4,922 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
|
| AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 ) |
| Policy contract number | 71740 |
| Policy instance | 1 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $126 | | 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 $126 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TSO5993137 |
| Policy instance | 4 |
| Insurance contract or identification number | TSO5993137 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $1,259 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ADD | | 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 $6,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $923 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 71740 |
| Policy instance | 2 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $158 | | 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 $158 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 71740 |
| Policy instance | 3 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $1,317 | | 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 $1,317 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 71740 |
| Policy instance | 2 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $1,488 | | 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 $1,488 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TSO5993137 |
| Policy instance | 4 |
| Insurance contract or identification number | TSO5993137 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $1,030 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $6,242 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $770 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 71740 |
| Policy instance | 3 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $2,351 | | 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 $2,351 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 ) |
| Policy contract number | 71740 |
| Policy instance | 1 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $31 | | 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 $31 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G0008321 |
| Policy instance | 4 |
| Insurance contract or identification number | G0008321 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $918 | | Total amount of fees paid to insurance company | USD $245 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ADD | | 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 $6,122 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $918 | | Amount paid for insurance broker fees | 245 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD ADMINISTRATION | | Insurance broker organization code? | 3 | | Insurance broker name | BROKER CONCEPTS, INC. |
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| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 71740 |
| Policy instance | 3 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $1,475 | | 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 $1,475 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 ) |
| Policy contract number | 71740 |
| Policy instance | 1 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $24 | | 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 $24 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 71740 |
| Policy instance | 2 |
| Insurance contract or identification number | 71740 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $2,340 | | 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 $2,340 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CONCEPTS, INC. |
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