STAT IMAGING SOLUTIONS, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN
401k plan membership statisitcs for STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN
Measure | Date | Value |
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2022: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-06-01 | 160 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 158 |
Number of retired or separated participants receiving benefits | 2022-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
Total of all active and inactive participants | 2022-06-01 | 158 |
2021: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-06-01 | 195 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 160 |
Number of retired or separated participants receiving benefits | 2021-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-06-01 | 0 |
Total of all active and inactive participants | 2021-06-01 | 160 |
2020: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-06-01 | 269 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 189 |
Number of retired or separated participants receiving benefits | 2020-06-01 | 6 |
Number of other retired or separated participants entitled to future benefits | 2020-06-01 | 0 |
Total of all active and inactive participants | 2020-06-01 | 195 |
2019: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-06-01 | 317 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 264 |
Number of retired or separated participants receiving benefits | 2019-06-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2019-06-01 | 0 |
Total of all active and inactive participants | 2019-06-01 | 269 |
2018: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-06-01 | 259 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 312 |
Number of retired or separated participants receiving benefits | 2018-06-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
Total of all active and inactive participants | 2018-06-01 | 317 |
2017: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-06-01 | 317 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 259 |
Number of retired or separated participants receiving benefits | 2017-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 0 |
Total of all active and inactive participants | 2017-06-01 | 259 |
2016: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-06-01 | 131 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 317 |
Number of retired or separated participants receiving benefits | 2016-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 0 |
Total of all active and inactive participants | 2016-06-01 | 317 |
2015: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-06-01 | 249 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 129 |
Number of retired or separated participants receiving benefits | 2015-06-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 0 |
Total of all active and inactive participants | 2015-06-01 | 131 |
2014: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-06-01 | 394 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 247 |
Number of retired or separated participants receiving benefits | 2014-06-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 0 |
Total of all active and inactive participants | 2014-06-01 | 249 |
2013: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-06-01 | 199 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 394 |
Number of retired or separated participants receiving benefits | 2013-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
Total of all active and inactive participants | 2013-06-01 | 394 |
2012: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-06-01 | 219 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 199 |
Number of retired or separated participants receiving benefits | 2012-06-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 0 |
Total of all active and inactive participants | 2012-06-01 | 199 |
2022: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2022 form 5500 responses |
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2022-06-01 | Type of plan entity | Single employer plan |
2022-06-01 | Submission has been amended | No |
2022-06-01 | This submission is the final filing | No |
2022-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-06-01 | Plan is a collectively bargained plan | No |
2022-06-01 | Plan funding arrangement – Insurance | Yes |
2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-06-01 | Plan benefit arrangement – Insurance | Yes |
2022-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2021 form 5500 responses |
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2021-06-01 | Type of plan entity | Single employer plan |
2021-06-01 | Submission has been amended | No |
2021-06-01 | This submission is the final filing | No |
2021-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-06-01 | Plan is a collectively bargained plan | No |
2021-06-01 | Plan funding arrangement – Insurance | Yes |
2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-06-01 | Plan benefit arrangement – Insurance | Yes |
2021-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2020 form 5500 responses |
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2020-06-01 | Type of plan entity | Single employer plan |
2020-06-01 | Submission has been amended | No |
2020-06-01 | This submission is the final filing | No |
2020-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-06-01 | Plan is a collectively bargained plan | No |
2020-06-01 | Plan funding arrangement – Insurance | Yes |
2020-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-06-01 | Plan benefit arrangement – Insurance | Yes |
2020-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2019 form 5500 responses |
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2019-06-01 | Type of plan entity | Single employer plan |
2019-06-01 | Submission has been amended | No |
2019-06-01 | This submission is the final filing | No |
2019-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-06-01 | Plan is a collectively bargained plan | No |
2019-06-01 | Plan funding arrangement – Insurance | Yes |
2019-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-06-01 | Plan benefit arrangement – Insurance | Yes |
2019-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2018 form 5500 responses |
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2018-06-01 | Type of plan entity | Single employer plan |
2018-06-01 | Submission has been amended | No |
2018-06-01 | This submission is the final filing | No |
2018-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-06-01 | Plan is a collectively bargained plan | No |
2018-06-01 | Plan funding arrangement – Insurance | Yes |
2018-06-01 | Plan benefit arrangement – Insurance | Yes |
2017: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2017 form 5500 responses |
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2017-06-01 | Type of plan entity | Single employer plan |
2017-06-01 | Submission has been amended | No |
2017-06-01 | This submission is the final filing | No |
2017-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-06-01 | Plan is a collectively bargained plan | No |
2017-06-01 | Plan funding arrangement – Insurance | Yes |
2017-06-01 | Plan benefit arrangement – Insurance | Yes |
2016: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2016 form 5500 responses |
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2016-06-01 | Type of plan entity | Single employer plan |
2016-06-01 | Submission has been amended | No |
2016-06-01 | This submission is the final filing | No |
2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-06-01 | Plan is a collectively bargained plan | No |
2016-06-01 | Plan funding arrangement – Insurance | Yes |
2016-06-01 | Plan benefit arrangement – Insurance | Yes |
2015: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2015 form 5500 responses |
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2015-06-01 | Type of plan entity | Single employer plan |
2015-06-01 | Submission has been amended | No |
2015-06-01 | This submission is the final filing | No |
2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-06-01 | Plan is a collectively bargained plan | No |
2015-06-01 | Plan funding arrangement – Insurance | Yes |
2015-06-01 | Plan benefit arrangement – Insurance | Yes |
2014: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2014 form 5500 responses |
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2014-06-01 | Type of plan entity | Single employer plan |
2014-06-01 | Submission has been amended | No |
2014-06-01 | This submission is the final filing | No |
2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-06-01 | Plan is a collectively bargained plan | No |
2014-06-01 | Plan funding arrangement – Insurance | Yes |
2014-06-01 | Plan benefit arrangement – Insurance | Yes |
2013: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2013 form 5500 responses |
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2013-06-01 | Type of plan entity | Single employer plan |
2013-06-01 | Submission has been amended | No |
2013-06-01 | This submission is the final filing | No |
2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-06-01 | Plan is a collectively bargained plan | No |
2013-06-01 | Plan funding arrangement – Insurance | Yes |
2013-06-01 | Plan benefit arrangement – Insurance | Yes |
2012: STAT IMAGING SOLUTIONS, LLC HEALTH & WELFARE PLAN 2012 form 5500 responses |
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2012-06-01 | Type of plan entity | Single employer plan |
2012-06-01 | First time form 5500 has been submitted | Yes |
2012-06-01 | Submission has been amended | No |
2012-06-01 | This submission is the final filing | No |
2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-06-01 | Plan is a collectively bargained plan | No |
2012-06-01 | Plan funding arrangement – Insurance | Yes |
2012-06-01 | Plan benefit arrangement – Insurance | Yes |
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BQR9 |
Policy instance | 8 |
Insurance contract or identification number | GVTL0BQR9 | Number of Individuals Covered | 78 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $2,981 | Total amount of fees paid to insurance company | USD $6,545 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY LIFE AND AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $19,874 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,981 | Amount paid for insurance broker fees | 1094 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | L05746 |
Policy instance | 1 |
Insurance contract or identification number | L05746 | Number of Individuals Covered | 118 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | 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 | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $942,655 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC 0BQR9 |
Policy instance | 2 |
Insurance contract or identification number | GUC 0BQR9 | Number of Individuals Covered | 68 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $1,821 | Total amount of fees paid to insurance company | USD $2,749 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $18,212 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,821 | Amount paid for insurance broker fees | 746 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41877 |
Policy instance | 3 |
Insurance contract or identification number | 41877 | Number of Individuals Covered | 106 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $924 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $11,545 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $924 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDE0BQR9 |
Policy instance | 4 |
Insurance contract or identification number | GUDE0BQR9 | Number of Individuals Covered | 27 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $682 | Total amount of fees paid to insurance company | USD $694 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | 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 $4,550 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $682 | Amount paid for insurance broker fees | 194 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDH0BQR9 |
Policy instance | 5 |
Insurance contract or identification number | GUDH0BQR9 | Number of Individuals Covered | 29 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $971 | Total amount of fees paid to insurance company | USD $1,048 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | 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 $6,474 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $971 | Amount paid for insurance broker fees | 336 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0BQR9 |
Policy instance | 6 |
Insurance contract or identification number | GUG 0BQR9 | Number of Individuals Covered | 21 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $767 | Total amount of fees paid to insurance company | USD $1,166 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $7,665 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $767 | Amount paid for insurance broker fees | 323 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUPR0BQR9 |
Policy instance | 7 |
Insurance contract or identification number | GUPR0BQR9 | Number of Individuals Covered | 46 | Insurance policy start date | 2022-06-01 | Insurance policy end date | 2023-05-31 | Total amount of commissions paid to insurance broker | USD $2,317 | Total amount of fees paid to insurance company | USD $2,409 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $15,669 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,317 | Amount paid for insurance broker fees | 685 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 921385 |
Policy instance | 1 |
Insurance contract or identification number | 921385 | Number of Individuals Covered | 162 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $36,925 | 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 $911,320 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 36925 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC 0BQR9 |
Policy instance | 2 |
Insurance contract or identification number | GUC 0BQR9 | Number of Individuals Covered | 63 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $1,544 | Total amount of fees paid to insurance company | USD $1,963 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $15,438 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,544 | Amount paid for insurance broker fees | 265 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41877 |
Policy instance | 3 |
Insurance contract or identification number | 41877 | Number of Individuals Covered | 141 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $1,230 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $15,370 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,230 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDE0BQR9 |
Policy instance | 4 |
Insurance contract or identification number | GUDE0BQR9 | Number of Individuals Covered | 33 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $620 | Total amount of fees paid to insurance company | USD $582 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | 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 $4,134 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $620 | Amount paid for insurance broker fees | 127 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDH0BQR9 |
Policy instance | 5 |
Insurance contract or identification number | GUDH0BQR9 | Number of Individuals Covered | 41 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $1,260 | Total amount of fees paid to insurance company | USD $1,066 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | 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 $8,399 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,260 | Amount paid for insurance broker fees | 142 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0BQR9 |
Policy instance | 6 |
Insurance contract or identification number | GUG 0BQR9 | Number of Individuals Covered | 30 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $637 | Total amount of fees paid to insurance company | USD $819 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $6,366 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $637 | Amount paid for insurance broker fees | 119 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUPR0BQR9 |
Policy instance | 7 |
Insurance contract or identification number | GUPR0BQR9 | Number of Individuals Covered | 49 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $2,248 | Total amount of fees paid to insurance company | USD $1,900 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $14,986 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,248 | Amount paid for insurance broker fees | 251 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BQR9 |
Policy instance | 8 |
Insurance contract or identification number | GVTL0BQR9 | Number of Individuals Covered | 88 | Insurance policy start date | 2021-06-01 | Insurance policy end date | 2022-05-31 | Total amount of commissions paid to insurance broker | USD $4,360 | Total amount of fees paid to insurance company | USD $9,757 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY LIFE AND AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $29,066 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 6020 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 3 | Commission paid to Insurance Broker | USD $4,360 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 921385 |
Policy instance | 1 |
Insurance contract or identification number | 921385 | Number of Individuals Covered | 127 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $39,467 | 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 $937,949 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 39467 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC 0BQR9 |
Policy instance | 2 |
Insurance contract or identification number | GUC 0BQR9 | Number of Individuals Covered | 53 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $1,461 | Total amount of fees paid to insurance company | USD $1,734 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $14,607 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 1607 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 | Commission paid to Insurance Broker | USD $1,461 |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41877 |
Policy instance | 3 |
Insurance contract or identification number | 41877 | Number of Individuals Covered | 142 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $1,149 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $14,208 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,149 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDE0BQR9 |
Policy instance | 4 |
Insurance contract or identification number | GUDE0BQR9 | Number of Individuals Covered | 35 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $1,764 | Total amount of fees paid to insurance company | USD $1,361 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | 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 $11,757 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,764 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 1293 | Additional information about fees paid to insurance broker | ADMINISTRATION |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDH0BQR9 |
Policy instance | 5 |
Insurance contract or identification number | GUDH0BQR9 | Number of Individuals Covered | 32 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $1,361 | Total amount of fees paid to insurance company | USD $1,073 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT | 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 $9,075 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,361 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 998 | Additional information about fees paid to insurance broker | ADMINISTRATION |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0BQR9 |
Policy instance | 6 |
Insurance contract or identification number | GUG 0BQR9 | Number of Individuals Covered | 32 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $716 | Total amount of fees paid to insurance company | USD $835 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $7,160 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 788 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 | Commission paid to Insurance Broker | USD $716 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUPR0BQR9 |
Policy instance | 7 |
Insurance contract or identification number | GUPR0BQR9 | Number of Individuals Covered | 41 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $2,239 | Total amount of fees paid to insurance company | USD $1,767 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $14,930 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,239 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 1642 | Additional information about fees paid to insurance broker | ADMINISTRATION |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BQR9 |
Policy instance | 8 |
Insurance contract or identification number | GVTL0BQR9 | Number of Individuals Covered | 107 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2021-05-31 | Total amount of commissions paid to insurance broker | USD $4,639 | Total amount of fees paid to insurance company | USD $8,749 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $31,543 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 5017 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 3 | Commission paid to Insurance Broker | USD $4,639 |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | 00187063 |
Policy instance | 1 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 196 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $68,893 | Total amount of fees paid to insurance company | USD $3,158 | 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 $1,238,393 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $59,493 | Amount paid for insurance broker fees | 3158 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1077052 |
Policy instance | 2 |
Insurance contract or identification number | 1077052 | Number of Individuals Covered | 218 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $17,860 | Total amount of fees paid to insurance company | USD $915 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS AND ACCIDENT | 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 $93,558 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,755 | Amount paid for insurance broker fees | 915 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41877 |
Policy instance | 3 |
Insurance contract or identification number | 41877 | Number of Individuals Covered | 196 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $1,772 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $21,461 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $886 | Insurance broker organization code? | 3 |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41877 |
Policy instance | 6 |
Insurance contract or identification number | 41877 | Number of Individuals Covered | 200 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $1,413 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $17,657 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,413 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 52017 |
Policy instance | 5 |
Insurance contract or identification number | 52017 | Number of Individuals Covered | 104 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $5,846 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,846 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 52117 |
Policy instance | 4 |
Insurance contract or identification number | 52117 | Number of Individuals Covered | 111 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $4,403 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,403 | Insurance broker organization code? | 3 |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1077052 |
Policy instance | 3 |
Insurance contract or identification number | 1077052 | Number of Individuals Covered | 224 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $14,781 | Total amount of fees paid to insurance company | USD $1,210 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS AND ACCIDENT | 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 $100,452 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,781 | Amount paid for insurance broker fees | 1210 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
|
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | 00187063 |
Policy instance | 1 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 240 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $54,150 | 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 $1,160,117 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,075 | Insurance broker organization code? | 3 |
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COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | 00187063 |
Policy instance | 2 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 10 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | 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 $42,978 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | 00187063 |
Policy instance | 1 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 201 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $48,341 | 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 $994,695 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $48,341 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
|
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | 00187063 |
Policy instance | 2 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 5 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $45 | 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 $38,393 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $45 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
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UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
Policy contract number | 5476752 |
Policy instance | 3 |
Insurance contract or identification number | 5476752 | Number of Individuals Covered | 54 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $2,475 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $16,504 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,475 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1077052 |
Policy instance | 4 |
Insurance contract or identification number | 1077052 | Number of Individuals Covered | 218 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $12,258 | Total amount of fees paid to insurance company | USD $3,978 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $82,854 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,258 | Amount paid for insurance broker fees | 3978 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 52117 |
Policy instance | 5 |
Insurance contract or identification number | 52117 | Number of Individuals Covered | 111 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $4,942 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,942 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 52017 |
Policy instance | 6 |
Insurance contract or identification number | 52017 | Number of Individuals Covered | 53 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $2,535 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,535 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES LLC |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41877 |
Policy instance | 7 |
Insurance contract or identification number | 41877 | Number of Individuals Covered | 169 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $1,346 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $16,821 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,346 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | 00187063 |
Policy instance | 1 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 191 | Insurance policy start date | 2015-06-01 | Insurance policy end date | 2016-05-31 | Total amount of commissions paid to insurance broker | USD $4,079 | 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 | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $76,232 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,551 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
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COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | 00187063 |
Policy instance | 2 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 117 | Insurance policy start date | 2015-06-01 | Insurance policy end date | 2016-05-31 | Total amount of commissions paid to insurance broker | USD $36,709 | 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 $694,941 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $31,960 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
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ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
Policy contract number | 00187063 |
Policy instance | 3 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 107 | Insurance policy start date | 2015-06-01 | Insurance policy end date | 2016-05-31 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $6,163 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 0000013313 |
Policy instance | 4 |
Insurance contract or identification number | 0000013313 | Number of Individuals Covered | 358 | Insurance policy start date | 2015-06-01 | Insurance policy end date | 2015-07-31 | Total amount of commissions paid to insurance broker | USD $5,386 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | 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 $19,284 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,544 | Insurance broker organization code? | 3 | Insurance broker name | HEATHER D. SWANSON |
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UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
Policy contract number | 5476752 |
Policy instance | 5 |
Insurance contract or identification number | 5476752 | Number of Individuals Covered | 73 | Insurance policy start date | 2015-08-01 | Insurance policy end date | 2016-05-31 | Total amount of commissions paid to insurance broker | USD $9,001 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY AD&D,CRITICAL ILLNESS | 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 $46,676 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,644 | Insurance broker organization code? | 3 | Insurance broker name | JOHNSON INSURANCE SERVICES, LLC |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 0000013313 |
Policy instance | 4 |
Insurance contract or identification number | 0000013313 | Number of Individuals Covered | 358 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $41,946 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS | 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 $127,830 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,916 | Insurance broker organization code? | 3 | Insurance broker name | HEATHER D. SWANSON |
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ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
Policy contract number | 00187063 |
Policy instance | 3 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 247 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $5,698 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | 00187063 |
Policy instance | 2 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 141 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $39,563 | 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 $764,729 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $39,563 | Insurance broker organization code? | 3 | Insurance broker name | STELLARUS BENEFITS INC. |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | 00187063 |
Policy instance | 1 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 196 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $709 | 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 | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $85,233 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $709 | Insurance broker organization code? | 3 | Insurance broker name | STELLARUS BENEFITS, INC. |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | 00187063 |
Policy instance | 1 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 171 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $554 | 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 | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $54,819 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $554 | Insurance broker organization code? | 3 | Insurance broker name | STELLARUS BENEFITS, INC. |
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COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | 00187063 |
Policy instance | 2 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 142 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $25,002 | 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 $572,568 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $25,002 | Insurance broker organization code? | 3 | Insurance broker name | STELLARUS BENEFITS INC. |
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ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
Policy contract number | 00187063 |
Policy instance | 3 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 394 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $5,187 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
Policy contract number | 00187063 |
Policy instance | 3 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 199 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $246 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,630 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $246 | Insurance broker organization code? | 3 | Insurance broker name | SEBS WISCONSIN LLC |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | 00187063 |
Policy instance | 1 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 109 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $288 | 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 | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $42,289 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $288 | Insurance broker organization code? | 3 | Insurance broker name | STELLARUS BENEFITS, INC. |
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COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | 00187063 |
Policy instance | 2 |
Insurance contract or identification number | 00187063 | Number of Individuals Covered | 94 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $26,604 | 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 $396,559 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $26,604 | Insurance broker organization code? | 3 | Insurance broker name | STELLARUS BENEFITS INC. |
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