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WARM HEARTH WELFARE BENEFITS PLAN 401k Plan overview

Plan NameWARM HEARTH WELFARE BENEFITS PLAN
Plan identification number 501

WARM HEARTH WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

WARM HEARTH INC has sponsored the creation of one or more 401k plans.

Company Name:WARM HEARTH INC
Employer identification number (EIN):237378013
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WARM HEARTH WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01MOLLY NEVITT2023-04-21 MOLLY NEVITT2023-04-21
5012020-10-01MOLLY NEVITT2022-11-07 MOLLY NEVITT2022-11-07
5012018-10-01MOLLY NEVITT2022-11-07 MOLLY NEVITT2022-11-07
5012017-10-01MOLLY NEVITT2022-11-07 MOLLY NEVITT2022-11-07
5012016-10-01WAYNE HOWELL WAYNE HOWELL2018-07-12
5012015-10-01LORRAINE WACHSMAN LORRAINE WACHSMAN2017-06-27
5012015-04-01LORRAINE WACHSMAN LORRAINE WACHSMAN2016-02-24
5012014-04-01LORRAINE WACHSMAN LORRAINE WACHSMAN2016-01-14
5012013-04-01LORRAINE WACHSMAN
5012012-04-01LORRAINE WACHSMAN LORRAINE WACHSMAN2013-10-11
5012011-04-01LORRAINE WACHSMAN
5012010-04-01LORRAINE WACHSMAN
5012009-04-01LORRAINE WACHSMAN
5012008-04-01 LORRAINE WACHSMAN2010-05-07
5012007-04-01 LORRAINE WACHSMAN2010-05-07
5012006-04-01 LORRAINE WACHSMAN2010-05-07
5012005-04-01 LORRAINE WACHSMAN2010-05-07
5012004-04-01 LORRAINE WACHSMAN2010-05-07
5012003-04-01 LORRAINE WACHSMAN2010-05-07
5012002-04-01 LORRAINE WACHSMAN2010-05-07
5012001-04-01 LORRAINE WACHSMAN2010-05-07

Plan Statistics for WARM HEARTH WELFARE BENEFITS PLAN

401k plan membership statisitcs for WARM HEARTH WELFARE BENEFITS PLAN

Measure Date Value
2021: WARM HEARTH WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01116
Total number of active participants reported on line 7a of the Form 55002021-10-01165
Total of all active and inactive participants2021-10-01165
2020: WARM HEARTH WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01117
Total number of active participants reported on line 7a of the Form 55002020-10-01116
Total of all active and inactive participants2020-10-01116
2018: WARM HEARTH WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01134
Total number of active participants reported on line 7a of the Form 55002018-10-01123
Total of all active and inactive participants2018-10-01123
2017: WARM HEARTH WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01146
Total number of active participants reported on line 7a of the Form 55002017-10-01134
Total of all active and inactive participants2017-10-01134
2016: WARM HEARTH WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01139
Total number of active participants reported on line 7a of the Form 55002016-10-01146
Total of all active and inactive participants2016-10-01146
Total participants2016-10-01146
2015: WARM HEARTH WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01187
Total number of active participants reported on line 7a of the Form 55002015-10-01139
Total of all active and inactive participants2015-10-01139
Total participants2015-10-01139
Total participants, beginning-of-year2015-04-01187
Total number of active participants reported on line 7a of the Form 55002015-04-01187
Total of all active and inactive participants2015-04-01187
Total participants2015-04-01187
2014: WARM HEARTH WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-04-01167
Total number of active participants reported on line 7a of the Form 55002014-04-01187
Total of all active and inactive participants2014-04-01187
Total participants2014-04-01187
2013: WARM HEARTH WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-04-01172
Total number of active participants reported on line 7a of the Form 55002013-04-01167
Total of all active and inactive participants2013-04-01167
Total participants2013-04-01167
2012: WARM HEARTH WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-04-01178
Total number of active participants reported on line 7a of the Form 55002012-04-01172
Number of retired or separated participants receiving benefits2012-04-010
Number of other retired or separated participants entitled to future benefits2012-04-010
Total of all active and inactive participants2012-04-01172
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2012-04-010
Total participants2012-04-01172
2011: WARM HEARTH WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-04-01175
Total number of active participants reported on line 7a of the Form 55002011-04-01178
Number of retired or separated participants receiving benefits2011-04-010
Number of other retired or separated participants entitled to future benefits2011-04-010
Total of all active and inactive participants2011-04-01178
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2011-04-010
Total participants2011-04-01178
2010: WARM HEARTH WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-04-01171
Total number of active participants reported on line 7a of the Form 55002010-04-01175
Number of retired or separated participants receiving benefits2010-04-010
Number of other retired or separated participants entitled to future benefits2010-04-010
Total of all active and inactive participants2010-04-01175
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2010-04-010
Total participants2010-04-01175
2009: WARM HEARTH WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-04-01166
Total number of active participants reported on line 7a of the Form 55002009-04-01171
Number of retired or separated participants receiving benefits2009-04-010
Number of other retired or separated participants entitled to future benefits2009-04-010
Total of all active and inactive participants2009-04-01171
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-04-010
Total participants2009-04-01171
2008: WARM HEARTH WELFARE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year2008-04-01156
Total number of active participants reported on line 7a of the Form 55002008-04-01166
Number of retired or separated participants receiving benefits2008-04-010
Number of other retired or separated participants entitled to future benefits2008-04-010
Total of all active and inactive participants2008-04-01166
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2008-04-010
Total participants2008-04-01166
2007: WARM HEARTH WELFARE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year2007-04-01158
Total number of active participants reported on line 7a of the Form 55002007-04-01160
Number of retired or separated participants receiving benefits2007-04-010
Number of other retired or separated participants entitled to future benefits2007-04-010
Total of all active and inactive participants2007-04-01160
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2007-04-010
Total participants2007-04-01160
2006: WARM HEARTH WELFARE BENEFITS PLAN 2006 401k membership
Total participants, beginning-of-year2006-04-01161
Total number of active participants reported on line 7a of the Form 55002006-04-01166
Number of retired or separated participants receiving benefits2006-04-010
Number of other retired or separated participants entitled to future benefits2006-04-010
Total of all active and inactive participants2006-04-01166
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2006-04-010
Total participants2006-04-01166
2005: WARM HEARTH WELFARE BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year2005-04-01151
Total number of active participants reported on line 7a of the Form 55002005-04-01170
Number of retired or separated participants receiving benefits2005-04-010
Number of other retired or separated participants entitled to future benefits2005-04-010
Total of all active and inactive participants2005-04-01170
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2005-04-010
Total participants2005-04-01170
2004: WARM HEARTH WELFARE BENEFITS PLAN 2004 401k membership
Total participants, beginning-of-year2004-04-01142
Total number of active participants reported on line 7a of the Form 55002004-04-01160
Number of retired or separated participants receiving benefits2004-04-010
Number of other retired or separated participants entitled to future benefits2004-04-010
Total of all active and inactive participants2004-04-01160
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2004-04-010
Total participants2004-04-01160
2003: WARM HEARTH WELFARE BENEFITS PLAN 2003 401k membership
Total participants, beginning-of-year2003-04-01129
Total number of active participants reported on line 7a of the Form 55002003-04-01143
Number of retired or separated participants receiving benefits2003-04-010
Number of other retired or separated participants entitled to future benefits2003-04-010
Total of all active and inactive participants2003-04-01143
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2003-04-010
Total participants2003-04-01143
2002: WARM HEARTH WELFARE BENEFITS PLAN 2002 401k membership
Total participants, beginning-of-year2002-04-01137
Total number of active participants reported on line 7a of the Form 55002002-04-01129
Number of retired or separated participants receiving benefits2002-04-010
Number of other retired or separated participants entitled to future benefits2002-04-010
Total of all active and inactive participants2002-04-01129
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2002-04-010
Total participants2002-04-01129
2001: WARM HEARTH WELFARE BENEFITS PLAN 2001 401k membership
Total participants, beginning-of-year2001-04-01127
Total number of active participants reported on line 7a of the Form 55002001-04-01133
Number of retired or separated participants receiving benefits2001-04-010
Number of other retired or separated participants entitled to future benefits2001-04-010
Total of all active and inactive participants2001-04-01133
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2001-04-010
Total participants2001-04-01133

Form 5500 Responses for WARM HEARTH WELFARE BENEFITS PLAN

2021: WARM HEARTH WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – General assets of the sponsorYes
2021-10-01Plan benefit arrangement – InsuranceYes
2020: WARM HEARTH WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – General assets of the sponsorYes
2020-10-01Plan benefit arrangement – InsuranceYes
2018: WARM HEARTH WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Plan funding arrangement – General assets of the sponsorYes
2018-10-01Plan benefit arrangement – InsuranceYes
2017: WARM HEARTH WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Plan funding arrangement – General assets of the sponsorYes
2017-10-01Plan benefit arrangement – InsuranceYes
2016: WARM HEARTH WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – General assets of the sponsorYes
2016-10-01Plan benefit arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – General assets of the sponsorYes
2015: WARM HEARTH WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – General assets of the sponsorYes
2015-10-01Plan benefit arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – General assets of the sponsorYes
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – General assets of the sponsorYes
2015-04-01Plan benefit arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – General assets of the sponsorYes
2014: WARM HEARTH WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Submission has been amendedNo
2014-04-01This submission is the final filingNo
2014-04-01This return/report is a short plan year return/report (less than 12 months)No
2014-04-01Plan is a collectively bargained planNo
2014-04-01Plan funding arrangement – General assets of the sponsorYes
2014-04-01Plan benefit arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – General assets of the sponsorYes
2013: WARM HEARTH WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01Submission has been amendedNo
2013-04-01This submission is the final filingNo
2013-04-01This return/report is a short plan year return/report (less than 12 months)No
2013-04-01Plan is a collectively bargained planNo
2013-04-01Plan funding arrangement – General assets of the sponsorYes
2013-04-01Plan benefit arrangement – InsuranceYes
2012: WARM HEARTH WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-04-01Type of plan entitySingle employer plan
2012-04-01Submission has been amendedNo
2012-04-01This submission is the final filingNo
2012-04-01This return/report is a short plan year return/report (less than 12 months)No
2012-04-01Plan is a collectively bargained planNo
2012-04-01Plan funding arrangement – InsuranceYes
2012-04-01Plan funding arrangement – General assets of the sponsorYes
2012-04-01Plan benefit arrangement – InsuranceYes
2012-04-01Plan benefit arrangement – General assets of the sponsorYes
2011: WARM HEARTH WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01Submission has been amendedNo
2011-04-01This submission is the final filingNo
2011-04-01This return/report is a short plan year return/report (less than 12 months)No
2011-04-01Plan is a collectively bargained planNo
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan funding arrangement – General assets of the sponsorYes
2011-04-01Plan benefit arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – General assets of the sponsorYes
2010: WARM HEARTH WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-04-01Type of plan entitySingle employer plan
2010-04-01Submission has been amendedNo
2010-04-01This submission is the final filingNo
2010-04-01This return/report is a short plan year return/report (less than 12 months)No
2010-04-01Plan is a collectively bargained planNo
2010-04-01Plan funding arrangement – InsuranceYes
2010-04-01Plan funding arrangement – General assets of the sponsorYes
2010-04-01Plan benefit arrangement – InsuranceYes
2010-04-01Plan benefit arrangement – General assets of the sponsorYes
2009: WARM HEARTH WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-04-01Type of plan entitySingle employer plan
2009-04-01Submission has been amendedNo
2009-04-01This submission is the final filingNo
2009-04-01This return/report is a short plan year return/report (less than 12 months)No
2009-04-01Plan is a collectively bargained planNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan funding arrangement – General assets of the sponsorYes
2009-04-01Plan benefit arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – General assets of the sponsorYes
2008: WARM HEARTH WELFARE BENEFITS PLAN 2008 form 5500 responses
2008-04-01Type of plan entitySingle employer plan
2008-04-01First time form 5500 has been submittedYes
2008-04-01Submission has been amendedNo
2008-04-01This submission is the final filingNo
2008-04-01This return/report is a short plan year return/report (less than 12 months)No
2008-04-01Plan is a collectively bargained planNo
2008-04-01Plan funding arrangement – InsuranceYes
2008-04-01Plan funding arrangement – General assets of the sponsorYes
2008-04-01Plan benefit arrangement – InsuranceYes
2008-04-01Plan benefit arrangement – General assets of the sponsorYes
2007: WARM HEARTH WELFARE BENEFITS PLAN 2007 form 5500 responses
2007-04-01Type of plan entitySingle employer plan
2007-04-01First time form 5500 has been submittedYes
2007-04-01Submission has been amendedNo
2007-04-01This submission is the final filingNo
2007-04-01This return/report is a short plan year return/report (less than 12 months)No
2007-04-01Plan is a collectively bargained planNo
2007-04-01Plan funding arrangement – InsuranceYes
2007-04-01Plan funding arrangement – General assets of the sponsorYes
2007-04-01Plan benefit arrangement – InsuranceYes
2007-04-01Plan benefit arrangement – General assets of the sponsorYes
2006: WARM HEARTH WELFARE BENEFITS PLAN 2006 form 5500 responses
2006-04-01Type of plan entitySingle employer plan
2006-04-01First time form 5500 has been submittedYes
2006-04-01Submission has been amendedNo
2006-04-01This submission is the final filingNo
2006-04-01This return/report is a short plan year return/report (less than 12 months)No
2006-04-01Plan is a collectively bargained planNo
2006-04-01Plan funding arrangement – InsuranceYes
2006-04-01Plan funding arrangement – General assets of the sponsorYes
2006-04-01Plan benefit arrangement – InsuranceYes
2006-04-01Plan benefit arrangement – General assets of the sponsorYes
2005: WARM HEARTH WELFARE BENEFITS PLAN 2005 form 5500 responses
2005-04-01Type of plan entitySingle employer plan
2005-04-01First time form 5500 has been submittedYes
2005-04-01Submission has been amendedNo
2005-04-01This submission is the final filingNo
2005-04-01This return/report is a short plan year return/report (less than 12 months)No
2005-04-01Plan is a collectively bargained planNo
2005-04-01Plan funding arrangement – InsuranceYes
2005-04-01Plan funding arrangement – General assets of the sponsorYes
2005-04-01Plan benefit arrangement – InsuranceYes
2005-04-01Plan benefit arrangement – General assets of the sponsorYes
2004: WARM HEARTH WELFARE BENEFITS PLAN 2004 form 5500 responses
2004-04-01Type of plan entitySingle employer plan
2004-04-01First time form 5500 has been submittedYes
2004-04-01Submission has been amendedNo
2004-04-01This submission is the final filingNo
2004-04-01This return/report is a short plan year return/report (less than 12 months)No
2004-04-01Plan is a collectively bargained planNo
2004-04-01Plan funding arrangement – InsuranceYes
2004-04-01Plan funding arrangement – General assets of the sponsorYes
2004-04-01Plan benefit arrangement – InsuranceYes
2004-04-01Plan benefit arrangement – General assets of the sponsorYes
2003: WARM HEARTH WELFARE BENEFITS PLAN 2003 form 5500 responses
2003-04-01Type of plan entitySingle employer plan
2003-04-01First time form 5500 has been submittedYes
2003-04-01Submission has been amendedNo
2003-04-01This submission is the final filingNo
2003-04-01This return/report is a short plan year return/report (less than 12 months)No
2003-04-01Plan is a collectively bargained planNo
2003-04-01Plan funding arrangement – InsuranceYes
2003-04-01Plan funding arrangement – General assets of the sponsorYes
2003-04-01Plan benefit arrangement – InsuranceYes
2003-04-01Plan benefit arrangement – General assets of the sponsorYes
2002: WARM HEARTH WELFARE BENEFITS PLAN 2002 form 5500 responses
2002-04-01Type of plan entitySingle employer plan
2002-04-01First time form 5500 has been submittedYes
2002-04-01Submission has been amendedNo
2002-04-01This submission is the final filingNo
2002-04-01This return/report is a short plan year return/report (less than 12 months)No
2002-04-01Plan is a collectively bargained planNo
2002-04-01Plan funding arrangement – InsuranceYes
2002-04-01Plan funding arrangement – General assets of the sponsorYes
2002-04-01Plan benefit arrangement – InsuranceYes
2002-04-01Plan benefit arrangement – General assets of the sponsorYes
2001: WARM HEARTH WELFARE BENEFITS PLAN 2001 form 5500 responses
2001-04-01Type of plan entitySingle employer plan
2001-04-01First time form 5500 has been submittedYes
2001-04-01Submission has been amendedNo
2001-04-01This submission is the final filingNo
2001-04-01This return/report is a short plan year return/report (less than 12 months)No
2001-04-01Plan is a collectively bargained planNo
2001-04-01Plan funding arrangement – InsuranceYes
2001-04-01Plan funding arrangement – General assets of the sponsorYes
2001-04-01Plan benefit arrangement – InsuranceYes
2001-04-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number052607
Policy instance 6
Insurance contract or identification number052607
Number of Individuals Covered146
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99200261001
Policy instance 1
Insurance contract or identification number99200261001
Number of Individuals Covered150
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $1,050
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,050
Insurance broker organization code?3
QBE A&H (National Association of Insurance Commissioners NAIC id number: 39217 )
Policy contract numberLGS01417-20
Policy instance 2
Insurance contract or identification numberLGS01417-20
Number of Individuals Covered124
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,645
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $407,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1645
Additional information about fees paid to insurance brokerSUUPLEMENTAL COMPENSATION PAID
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160298
Policy instance 3
Insurance contract or identification number160298
Number of Individuals Covered165
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $10,895
Total amount of fees paid to insurance companyUSD $1,313
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,664
Insurance broker organization code?3
Amount paid for insurance broker fees1313
Additional information about fees paid to insurance brokerADMINISTRATION
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0010549169
Policy instance 4
Insurance contract or identification number0010549169
Number of Individuals Covered36
Insurance policy start date2021-10-01
Insurance policy end date2022-10-01
Total amount of commissions paid to insurance brokerUSD $541
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $378
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0579300
Policy instance 5
Insurance contract or identification numberR0579300
Number of Individuals Covered69
Insurance policy start date2021-10-01
Insurance policy end date2022-10-01
Total amount of commissions paid to insurance brokerUSD $1,169
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedGCIEE, GRPACCVO, GRPHSPVO
Welfare Benefit Premiums Paid to CarrierUSD $17,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $819
Insurance broker organization code?3
QBE A&H (National Association of Insurance Commissioners NAIC id number: 39217 )
Policy contract numberLGS01417-20
Policy instance 3
Insurance contract or identification numberLGS01417-20
Number of Individuals Covered124
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,900
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $355,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1900
Additional information about fees paid to insurance brokerOTHER COMPENSATION PAID
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99200261001
Policy instance 2
Insurance contract or identification number99200261001
Number of Individuals Covered164
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $1,027
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,027
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160298
Policy instance 4
Insurance contract or identification number160298
Number of Individuals Covered173
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $9,991
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,714
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0010549169
Policy instance 5
Insurance contract or identification number0010549169
Number of Individuals Covered46
Insurance policy start date2020-10-01
Insurance policy end date2021-10-01
Total amount of commissions paid to insurance brokerUSD $732
Total amount of fees paid to insurance companyUSD $20
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $512
Amount paid for insurance broker fees17
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0579300
Policy instance 6
Insurance contract or identification numberR0579300
Number of Individuals Covered87
Insurance policy start date2020-10-01
Insurance policy end date2021-10-01
Total amount of commissions paid to insurance brokerUSD $1,686
Total amount of fees paid to insurance companyUSD $85
Other welfare benefits providedGCIEE, GRPACCVO, GRPHSPVO
Welfare Benefit Premiums Paid to CarrierUSD $21,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,181
Amount paid for insurance broker fees72
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number52607
Policy instance 1
Insurance contract or identification number52607
Number of Individuals Covered149
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160298
Policy instance 4
Insurance contract or identification number160298
Number of Individuals Covered183
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $11,174
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,886
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99200261001
Policy instance 2
Insurance contract or identification number99200261001
Number of Individuals Covered169
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $1,329
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,329
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number052607
Policy instance 1
Insurance contract or identification number052607
Number of Individuals Covered155
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
QBE A&H (National Association of Insurance Commissioners NAIC id number: 39217 )
Policy contract numberLGS01417-18
Policy instance 3
Insurance contract or identification numberLGS01417-18
Number of Individuals Covered139
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $4,404
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $259,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees4404
Additional information about fees paid to insurance brokerOTHER COMPENSATION PAID
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0010549169
Policy instance 5
Insurance contract or identification number0010549169
Number of Individuals Covered74
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $4,322
Total amount of fees paid to insurance companyUSD $253
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,024
Amount paid for insurance broker fees251
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0579300
Policy instance 6
Insurance contract or identification numberR0579300
Number of Individuals Covered131
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $6,369
Total amount of fees paid to insurance companyUSD $8
Other welfare benefits providedGCIEE, GRPACCVO, GRPHSPVO
Welfare Benefit Premiums Paid to CarrierUSD $29,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,459
Insurance broker organization code?3
Amount paid for insurance broker fees8
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160298
Policy instance 4
Insurance contract or identification number160298
Number of Individuals Covered195
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $10,299
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,047
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0010549169
Policy instance 5
Insurance contract or identification number0010549169
Number of Individuals Covered74
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $3,289
Total amount of fees paid to insurance companyUSD $213
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,302
Amount paid for insurance broker fees172
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
QBE A&H (National Association of Insurance Commissioners NAIC id number: 39217 )
Policy contract numberLGS01417-17
Policy instance 3
Insurance contract or identification numberLGS01417-17
Number of Individuals Covered143
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $4,999
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $224,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees4999
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION PAID
Insurance broker organization code?3
HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )
Policy contract number52607
Policy instance 1
Insurance contract or identification number52607
Number of Individuals Covered134
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0579300
Policy instance 6
Insurance contract or identification numberR0579300
Number of Individuals Covered146
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $6,886
Total amount of fees paid to insurance companyUSD $781
Other welfare benefits providedGCIEE, GRPACCVO, GRPHSPVO
Welfare Benefit Premiums Paid to CarrierUSD $33,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,823
Amount paid for insurance broker fees630
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99200261001
Policy instance 2
Insurance contract or identification number99200261001
Number of Individuals Covered173
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $1,124
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,124
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0865112
Policy instance 4
Insurance contract or identification number0865112
Number of Individuals Covered183
Insurance policy start date2015-04-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $10,991
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $39,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,685
Insurance broker organization code?3
Insurance broker nameJAMES A SCOTT & SON INC
HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )
Policy contract number52607
Policy instance 3
Insurance contract or identification number52607
Number of Individuals Covered170
Insurance policy start date2015-04-01
Insurance policy end date2015-09-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $347,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9920026
Policy instance 2
Insurance contract or identification number9920026
Number of Individuals Covered158
Insurance policy start date2015-04-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $443
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $4,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $443
Insurance broker organization code?3
Insurance broker nameJAMES A SCOTT & SON INC
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number000700119
Policy instance 1
Insurance contract or identification number000700119
Number of Individuals Covered187
Insurance policy start date2015-04-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $465
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $3,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees465
Additional information about fees paid to insurance brokerCLAIMS ADMINISTRATOR
Insurance broker organization code?5
Insurance broker nameDELTA DENTAL OF VIRGINIA
UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )
Policy contract number0HHU OHHV OZID
Policy instance 1
Insurance contract or identification number0HHU OHHV OZID
Number of Individuals Covered132
Insurance policy start date2014-04-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $78
Total amount of fees paid to insurance companyUSD $12,649
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $552,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees6473
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $78
Insurance broker nameJAMES A SCOTT & SON INC
HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )
Policy contract number52607
Policy instance 2
Insurance contract or identification number52607
Number of Individuals Covered170
Insurance policy start date2014-10-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $41,565
Total amount of fees paid to insurance companyUSD $24,956
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $355,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,565
Amount paid for insurance broker fees23093
Insurance broker organization code?3
Insurance broker nameJAMES A SCOTT & SON INC
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number000100510
Policy instance 3
Insurance contract or identification number000100510
Number of Individuals Covered187
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $2,305
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $28,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,724
Insurance broker organization code?3
Insurance broker nameJAMES A SCOTT & SON INC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0865112
Policy instance 4
Insurance contract or identification number0865112
Number of Individuals Covered183
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $14,934
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $79,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,685
Insurance broker organization code?3
Insurance broker nameJAMES A SCOTT & SON INC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9920026
Policy instance 6
Insurance contract or identification number9920026
Number of Individuals Covered158
Insurance policy start date2014-10-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $443
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $4,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $443
Insurance broker organization code?3
Insurance broker nameJAMES A SCOTT & SON INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number443025
Policy instance 5
Insurance contract or identification number443025
Number of Individuals Covered99
Insurance policy start date2014-04-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $553
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $5,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $278
Insurance broker organization code?3
Insurance broker nameJAMES A SCOTT & SON INC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0865112
Policy instance 3
Insurance contract or identification number0865112
Number of Individuals Covered186
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $76,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number000100510
Policy instance 2
Insurance contract or identification number000100510
Number of Individuals Covered157
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $4,279
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $46,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,279
Insurance broker organization code?3
Insurance broker nameRUTHERFOORD FINANCIAL SERVICES INC
UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )
Policy contract number0HHU OHHV OZID
Policy instance 1
Insurance contract or identification number0HHU OHHV OZID
Number of Individuals Covered167
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $78
Total amount of fees paid to insurance companyUSD $21,805
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $960,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $78
Amount paid for insurance broker fees21805
Insurance broker organization code?3
Insurance broker nameRUTHERFOORD BENEFIT SERVICES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number443025
Policy instance 4
Insurance contract or identification number443025
Number of Individuals Covered96
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $914
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $9,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $914
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameRUTHERFOORD FINANCIAL SVCS INC
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number9071479955
Policy instance 2
Insurance contract or identification number9071479955
Number of Individuals Covered172
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $6,364
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $54,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,364
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameJAMES A. SCOTT & SON, INC.
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5346644
Policy instance 3
Insurance contract or identification number5346644
Number of Individuals Covered156
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $6,241
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $49,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,598
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameRUTHERFOORD FINANCIAL SERVICES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number443025
Policy instance 4
Insurance contract or identification number443025
Number of Individuals Covered86
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $960
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $584
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameRUTHERFOORD FINANCIAL SERVICES INC.
UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )
Policy contract number0HHU 0HHV 0ZID
Policy instance 1
Insurance contract or identification number0HHU 0HHV 0ZID
Number of Individuals Covered142
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $18,446
Total amount of fees paid to insurance companyUSD $197
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $819,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,030
Amount paid for insurance broker fees238
Insurance broker organization code?3
Insurance broker nameRUTHERFORD BENEFIT SERVICES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number443025
Policy instance 4
Insurance contract or identification number443025
Number of Individuals Covered86
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $866
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number9071479955
Policy instance 1
Insurance contract or identification number9071479955
Number of Individuals Covered178
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $6,183
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $54,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5346644
Policy instance 2
Insurance contract or identification number5346644
Number of Individuals Covered156
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $6,261
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $49,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )
Policy contract number0HHU
Policy instance 3
Insurance contract or identification number0HHU
Number of Individuals Covered145
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $18,221
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $809,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number9071479955
Policy instance 1
Insurance contract or identification number9071479955
Number of Individuals Covered175
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $5,930
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $51,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED HEALTHCARE (National Association of Insurance Commissioners NAIC id number: 95378 )
Policy contract number0HHU
Policy instance 3
Insurance contract or identification number0HHU
Number of Individuals Covered160
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $16,304
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $657,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number443025
Policy instance 4
Insurance contract or identification number443025
Number of Individuals Covered83
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $791
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5346644
Policy instance 2
Insurance contract or identification number5346644
Number of Individuals Covered156
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $5,129
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $40,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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