SCULPTZ, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan HOSIERY CORPORATION OF AMERICA MEDICAL PLAN
| Measure | Date | Value |
|---|
| 2018: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 8 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 8 |
| 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 | 8 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2018-01-01 | 0 |
| Total participants | 2018-01-01 | 8 |
| 2017: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 21 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 8 |
| 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 | 8 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-01-01 | 0 |
| Total participants | 2017-01-01 | 8 |
| 2016: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 76 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 21 |
| 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 | 21 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2016-01-01 | 0 |
| Total participants | 2016-01-01 | 21 |
| 2015: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 78 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 76 |
| 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 | 76 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-01-01 | 0 |
| Total participants | 2015-01-01 | 76 |
| 2014: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 85 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 78 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 78 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-01-01 | 0 |
| Total participants | 2014-01-01 | 78 |
| 2013: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 93 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 85 |
| 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 | 85 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-01-01 | 0 |
| Total participants | 2013-01-01 | 85 |
| 2012: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 93 |
| 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 | 93 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2012-01-01 | 0 |
| Total participants | 2012-01-01 | 93 |
| 2011: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 41 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 24 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 24 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2011-01-01 | 0 |
| Total participants | 2011-01-01 | 24 |
| 2009: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 61 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 49 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 49 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-01-01 | 0 |
| Total participants | 2009-01-01 | 49 |
| 2018: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: HOSIERY CORPORATION OF AMERICA MEDICAL 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 benefit arrangement – Insurance | Yes |
| 2015: HOSIERY CORPORATION OF AMERICA MEDICAL 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 benefit arrangement – Insurance | Yes |
| 2014: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: HOSIERY CORPORATION OF AMERICA MEDICAL 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 benefit arrangement – Insurance | Yes |
| 2012: HOSIERY CORPORATION OF AMERICA MEDICAL 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 benefit arrangement – Insurance | Yes |
| 2011: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: HOSIERY CORPORATION OF AMERICA MEDICAL PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00360197 |
| Policy instance | 3 |
| Insurance contract or identification number | 00360197 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $1,086 | | Total amount of fees paid to insurance company | USD $108 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,874 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,086 | | Amount paid for insurance broker fees | 108 | | Insurance broker organization code? | 3 |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 2 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $1,170 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $36,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,170 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 1 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $3,744 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $58,403 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,744 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-350020 |
| Policy instance | 4 |
| Insurance contract or identification number | 010-350020 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $32 | | Total amount of fees paid to insurance company | USD $17 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $643 | | 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 | | Amount paid for insurance broker fees | 17 | | Insurance broker organization code? | 3 |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 1 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $3,900 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $94,868 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,900 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00360197 |
| Policy instance | 3 |
| Insurance contract or identification number | 00360197 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $995 | | Total amount of fees paid to insurance company | USD $107 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $331 | | Amount paid for insurance broker fees | 107 | | Additional information about fees paid to insurance broker | CONTRACT ID 0009K574 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 2 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $3,432 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $55,117 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,432 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-350020 |
| Policy instance | 4 |
| Insurance contract or identification number | 010-350020 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $308 | | Total amount of fees paid to insurance company | USD $170 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,166 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $308 | | Amount paid for insurance broker fees | 170 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 1 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $38,922 | | 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 $38,922 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 2 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | 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 | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 3 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | 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 | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00360197 |
| Policy instance | 5 |
| Insurance contract or identification number | 00360197 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $1,034 | | Total amount of fees paid to insurance company | USD $120 | | 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 $10,724 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,029 | | Amount paid for insurance broker fees | 120 | | Insurance broker organization code? | 3 | | Insurance broker name | INDEPENDENCE PLANNING GROUP LLC |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-350020 |
| Policy instance | 6 |
| Insurance contract or identification number | 010-350020 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $1,903 | | Total amount of fees paid to insurance company | USD $1,128 | | 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 $38,059 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,903 | | Amount paid for insurance broker fees | 1128 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 4 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $5,889 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $114,646 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,889 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00360197 |
| Policy instance | 5 |
| Insurance contract or identification number | 00360197 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $1,114 | | Total amount of fees paid to insurance company | USD $98 | | 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 $11,298 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,108 | | Amount paid for insurance broker fees | 98 | | Insurance broker organization code? | 3 | | Insurance broker name | INDEPENDENCE PLANNING GROUP, LLC |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-350020 |
| Policy instance | 6 |
| Insurance contract or identification number | 010-350020 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $2,218 | | Total amount of fees paid to insurance company | USD $1,101 | | 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 $44,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,218 | | Amount paid for insurance broker fees | 1101 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 4 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $6,666 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $146,232 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,666 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 3 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | 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 | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 2 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | 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 | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 1 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $40,395 | | 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 $40,395 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 2 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $7,010 | | 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 | 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 $7,010 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 1 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $35,568 | | 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 $35,568 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00360197 |
| Policy instance | 5 |
| Insurance contract or identification number | 00360197 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $1,114 | | Total amount of fees paid to insurance company | USD $134 | | 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 $11,789 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,108 | | Amount paid for insurance broker fees | 134 | | Insurance broker organization code? | 3 | | Insurance broker name | INDEPENDENCE PLANNING GROUP, LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 3 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $402 | | 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 | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $402 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 4 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $6,067 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $147,978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,067 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-350020 |
| Policy instance | 6 |
| Insurance contract or identification number | 010-350020 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $2,207 | | 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 $44,146 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,207 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 2 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $7,963 | | Total amount of fees paid to insurance company | USD $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 $7,963 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 3 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $403 | | Total amount of fees paid to insurance company | USD $0 | | Vision 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 $403 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 4 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $9,903 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $241,541 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,903 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-350020 |
| Policy instance | 6 |
| Insurance contract or identification number | 010-350020 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $3,314 | | Total amount of fees paid to insurance company | USD $1,120 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,669 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,430 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK III BROKERAGE INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00360197 |
| Policy instance | 5 |
| Insurance contract or identification number | 00360197 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $1,625 | | Total amount of fees paid to insurance company | USD $203 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,237 | | 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 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 1 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $38,399 | | 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 $38,399 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00360197 |
| Policy instance | 5 |
| Insurance contract or identification number | 00360197 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $1,976 | | Total amount of fees paid to insurance company | USD $228 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,941 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 4 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $10,773 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $262,752 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 2 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $10,773 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 1 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $46,154 | | 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 |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 3 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $538 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00360197 |
| Policy instance | 5 |
| Insurance contract or identification number | 00360197 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Total amount of commissions paid to insurance broker | USD $2,504 | | Total amount of fees paid to insurance company | USD $73 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,504 | | Amount paid for insurance broker fees | 73 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 4 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Total amount of commissions paid to insurance broker | USD $12,842 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $313,231 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,842 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 ) |
| Policy contract number | 358955 |
| Policy instance | 3 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Total amount of commissions paid to insurance broker | USD $266 | | Total amount of fees paid to insurance company | USD $0 | | Vision 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 $266 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 2 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Total amount of commissions paid to insurance broker | USD $5,389 | | Total amount of fees paid to insurance company | USD $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 $5,389 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 358955 |
| Policy instance | 1 |
| Insurance contract or identification number | 358955 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Total amount of commissions paid to insurance broker | USD $24,053 | | 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 $24,053 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
