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SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN 401k Plan overview

Plan NameSHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN
Plan identification number 501

SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

SHEPLERS, INC. has sponsored the creation of one or more 401k plans.

Company Name:SHEPLERS, INC.
Employer identification number (EIN):260604311
NAIC Classification:448150
NAIC Description:Clothing Accessories Stores

Additional information about SHEPLERS, INC.

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2010-01-08
Company Identification Number: 0801215713
Legal Registered Office Address: 15345 BARRANCA PKWY

IRVINE
United States of America (USA)
92618

More information about SHEPLERS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012015-08-01
5012014-08-01LAURA HOHL
5012013-08-01
5012013-01-01

Plan Statistics for SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN

401k plan membership statisitcs for SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN

Measure Date Value
2015: SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year2015-08-01337
Total number of active participants reported on line 7a of the Form 55002015-08-010
Number of retired or separated participants receiving benefits2015-08-010
Number of other retired or separated participants entitled to future benefits2015-08-010
Total of all active and inactive participants2015-08-010
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2015-08-010
Total participants2015-08-010
Number of participants with account balances2015-08-010
2014: SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year2014-08-01245
Total number of active participants reported on line 7a of the Form 55002014-08-01337
Total of all active and inactive participants2014-08-01337
Total participants2014-08-01337
2013: SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year2013-08-01372
Total number of active participants reported on line 7a of the Form 55002013-08-01245
Total of all active and inactive participants2013-08-01245
Total participants2013-08-01245
Total participants, beginning-of-year2013-01-01215
Total number of active participants reported on line 7a of the Form 55002013-01-01372
Total of all active and inactive participants2013-01-01372
Total participants2013-01-01372

Form 5500 Responses for SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN

2015: SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN 2015 form 5500 responses
2015-08-01Type of plan entitySingle employer plan
2015-08-01This submission is the final filingYes
2015-08-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-08-01Plan funding arrangement – InsuranceYes
2015-08-01Plan benefit arrangement – InsuranceYes
2014: SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN 2014 form 5500 responses
2014-08-01Type of plan entitySingle employer plan
2014-08-01Plan funding arrangement – InsuranceYes
2014-08-01Plan benefit arrangement – InsuranceYes
2013: SHEPLERS, INC. GROUP LIFE AND MEDICAL PLAN 2013 form 5500 responses
2013-08-01Type of plan entitySingle employer plan
2013-08-01Submission has been amendedNo
2013-08-01This submission is the final filingNo
2013-08-01This return/report is a short plan year return/report (less than 12 months)No
2013-08-01Plan is a collectively bargained planNo
2013-08-01Plan funding arrangement – InsuranceYes
2013-08-01Plan benefit arrangement – InsuranceYes
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number52580
Policy instance 8
Insurance contract or identification number52580
Number of Individuals Covered62
Insurance policy start date2015-08-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $796
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $796
Insurance broker organization code?3
Insurance broker nameDANIEL D NELSON
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9844531
Policy instance 1
Insurance contract or identification number9844531
Number of Individuals Covered252
Insurance policy start date2015-08-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $208
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $208
Insurance broker organization code?3
Insurance broker nameDANIEL DAVID NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961133
Policy instance 2
Insurance contract or identification numberVDT961133
Number of Individuals Covered0
Insurance policy start date2015-08-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $885
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $885
Insurance broker organization code?3
Insurance broker nameDANIEL D NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961134
Policy instance 3
Insurance contract or identification numberVDT961134
Number of Individuals Covered0
Insurance policy start date2015-08-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $497
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $124
Insurance broker organization code?7
Insurance broker nameDANIEL D NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 966235
Policy instance 4
Insurance contract or identification numberOK 966235
Number of Individuals Covered0
Insurance policy start date2015-08-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $147
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $147
Insurance broker organization code?3
Insurance broker nameDANIEL D NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX964648
Policy instance 5
Insurance contract or identification numberFLX964648
Number of Individuals Covered0
Insurance policy start date2015-08-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $1,033
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $304
Insurance broker organization code?7
Insurance broker nameDANIEL D NELSON
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number755387
Policy instance 6
Insurance contract or identification number755387
Number of Individuals Covered190
Insurance policy start date2015-08-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $18,410
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $304,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,410
Insurance broker organization code?3
Insurance broker nameDANIEL DAVID NELSON
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number52581
Policy instance 7
Insurance contract or identification number52581
Number of Individuals Covered97
Insurance policy start date2015-08-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $532
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $532
Insurance broker organization code?3
Insurance broker nameDANIEL D NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961133
Policy instance 2
Insurance contract or identification numberVDT961133
Number of Individuals Covered223
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $5,829
Total amount of fees paid to insurance companyUSD $408
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees408
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?7
Commission paid to Insurance BrokerUSD $5,829
Insurance broker nameDANIEL D NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961134
Policy instance 3
Insurance contract or identification numberVDT961134
Number of Individuals Covered155
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $4,374
Total amount of fees paid to insurance companyUSD $323
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,749
Amount paid for insurance broker fees323
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?7
Insurance broker nameDANIEL D NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 966235
Policy instance 4
Insurance contract or identification numberOK 966235
Number of Individuals Covered175
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $1,088
Total amount of fees paid to insurance companyUSD $95
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $5,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees95
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?7
Commission paid to Insurance BrokerUSD $1,088
Insurance broker nameDANIEL D NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX964648
Policy instance 5
Insurance contract or identification numberFLX964648
Number of Individuals Covered211
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $3,757
Total amount of fees paid to insurance companyUSD $686
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,757
Amount paid for insurance broker fees686
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?7
Insurance broker nameALTERITY GROUP
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number755387
Policy instance 6
Insurance contract or identification number755387
Number of Individuals Covered336
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $106,560
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,776,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $106,560
Insurance broker organization code?3
Insurance broker nameDANIEL DAVID NELSON
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number52581
Policy instance 7
Insurance contract or identification number52581
Number of Individuals Covered116
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $5,402
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $67,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,402
Insurance broker organization code?3
Insurance broker nameDANIEL D NELSON
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number52580
Policy instance 8
Insurance contract or identification number52580
Number of Individuals Covered54
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $2,424
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $30,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,424
Insurance broker organization code?3
Insurance broker nameDANIEL D NELSON
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9844531
Policy instance 1
Insurance contract or identification number9844531
Number of Individuals Covered276
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $2,290
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,290
Insurance broker organization code?3
Insurance broker nameDANIEL DAVID NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 966235
Policy instance 8
Insurance contract or identification numberOK 966235
Number of Individuals Covered175
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $1,137
Total amount of fees paid to insurance companyUSD $107
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,046
Insurance broker organization code?3
Amount paid for insurance broker fees107
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameWILLIS OF NEW YORK INC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9844531
Policy instance 1
Insurance contract or identification number9844531
Number of Individuals Covered245
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT 961133
Policy instance 2
Insurance contract or identification numberVDT 961133
Number of Individuals Covered223
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $5,981
Total amount of fees paid to insurance companyUSD $432
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,532
Insurance broker organization code?3
Amount paid for insurance broker fees432
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameWILLIS OF NEW YORK INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0755387
Policy instance 3
Insurance contract or identification number0755387
Number of Individuals Covered174
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $92,007
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,533,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $92,007
Insurance broker organization code?3
Insurance broker nameDANIEL DAVID NELSON
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number52581
Policy instance 5
Insurance contract or identification number52581
Number of Individuals Covered97
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $3,785
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $47,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,785
Insurance broker organization code?3
Insurance broker nameDANIEL DAVID NELSON
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number52580
Policy instance 4
Insurance contract or identification number52580
Number of Individuals Covered62
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $3,060
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $40,217
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,060
Insurance broker organization code?3
Insurance broker nameDANIEL DAVID NELSON
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT961134
Policy instance 6
Insurance contract or identification numberVDT961134
Number of Individuals Covered155
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $2,913
Total amount of fees paid to insurance companyUSD $377
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,602
Insurance broker organization code?3
Amount paid for insurance broker fees377
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameWILLIS OF NEW YORK INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX 964648
Policy instance 7
Insurance contract or identification numberFLX 964648
Number of Individuals Covered211
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $3,282
Total amount of fees paid to insurance companyUSD $759
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $40,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,913
Insurance broker organization code?3
Amount paid for insurance broker fees759
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameWILLIS OF NEW YORK INC
BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )
Policy contract number09151
Policy instance 2
Insurance contract or identification number09151
Number of Individuals Covered318
Insurance policy start date2013-03-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $26,309
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,309
Insurance broker organization code?3
Insurance broker nameWILLIS NORTH AMERICA
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05722448
Policy instance 3
Insurance contract or identification numberTM05722448
Number of Individuals Covered372
Insurance policy start date2013-01-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $2,340
Total amount of fees paid to insurance companyUSD $836
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $46,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,340
Amount paid for insurance broker fees836
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9844531
Policy instance 4
Insurance contract or identification number9844531
Number of Individuals Covered202
Insurance policy start date2013-01-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $536
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $536
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 966235
Policy instance 5
Insurance contract or identification numberOK 966235
Number of Individuals Covered201
Insurance policy start date2013-01-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $650
Total amount of fees paid to insurance companyUSD $262
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $87
Insurance broker organization code?3
Amount paid for insurance broker fees262
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameWILLIS OF NEW YORK INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT 961134
Policy instance 6
Insurance contract or identification numberVDT 961134
Number of Individuals Covered201
Insurance policy start date2013-01-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $2,131
Total amount of fees paid to insurance companyUSD $730
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $220
Insurance broker organization code?3
Amount paid for insurance broker fees730
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameWILLIS OF NEW YORK INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX 964648
Policy instance 8
Insurance contract or identification numberFLX 964648
Number of Individuals Covered201
Insurance policy start date2013-01-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $3,126
Total amount of fees paid to insurance companyUSD $1,637
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $206
Insurance broker organization code?3
Amount paid for insurance broker fees1637
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameWILLIS OF NEW YORK INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT 961133
Policy instance 7
Insurance contract or identification numberVDT 961133
Number of Individuals Covered201
Insurance policy start date2013-01-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $3,169
Total amount of fees paid to insurance companyUSD $480
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $430
Insurance broker organization code?3
Amount paid for insurance broker fees480
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameWILLIS OF NEW YORK INC
BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 )
Policy contract number09151
Policy instance 1
Insurance contract or identification number09151
Number of Individuals Covered312
Insurance policy start date2013-01-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $10,267
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $241,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,267
Insurance broker organization code?3
Insurance broker nameWILLIS NORTH AMERICA

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