ASU PREPARATORY ACADEMY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ASU PREPARATORY ACADEMY BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: ASU PREPARATORY ACADEMY BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 709 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 752 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 758 |
| Number of employers contributing to the scheme | 2022-07-01 | 0 |
| 2021: ASU PREPARATORY ACADEMY BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 579 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 706 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 709 |
| Number of employers contributing to the scheme | 2021-07-01 | 0 |
| 2020: ASU PREPARATORY ACADEMY BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 349 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 579 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 579 |
| Number of employers contributing to the scheme | 2020-07-01 | 0 |
| 2019: ASU PREPARATORY ACADEMY BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 380 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 349 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 352 |
| Number of employers contributing to the scheme | 2019-07-01 | 0 |
| 2018: ASU PREPARATORY ACADEMY BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 370 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 380 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 380 |
| Number of employers contributing to the scheme | 2018-07-01 | 0 |
| 2017: ASU PREPARATORY ACADEMY BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 263 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 370 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 0 |
| Total of all active and inactive participants | 2017-07-01 | 370 |
| Number of employers contributing to the scheme | 2017-07-01 | 0 |
| 2016: ASU PREPARATORY ACADEMY BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 261 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 0 |
| Total of all active and inactive participants | 2016-07-01 | 263 |
| 2015: ASU PREPARATORY ACADEMY BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 257 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 226 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 0 |
| Total of all active and inactive participants | 2015-07-01 | 228 |
| 2014: ASU PREPARATORY ACADEMY BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 170 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 257 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-07-01 | 0 |
| Total of all active and inactive participants | 2014-07-01 | 257 |
| 2013: ASU PREPARATORY ACADEMY BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 159 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 170 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-07-01 | 0 |
| Total of all active and inactive participants | 2013-07-01 | 170 |
| 2012: ASU PREPARATORY ACADEMY BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 137 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-07-01 | 0 |
| Total of all active and inactive participants | 2012-07-01 | 137 |
| 2011: ASU PREPARATORY ACADEMY BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 123 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 123 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-07-01 | 0 |
| Total of all active and inactive participants | 2011-07-01 | 123 |
| 2022: ASU PREPARATORY ACADEMY BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ASU PREPARATORY ACADEMY BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ASU PREPARATORY ACADEMY BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: ASU PREPARATORY ACADEMY BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ASU PREPARATORY ACADEMY BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ASU PREPARATORY ACADEMY BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ASU PREPARATORY ACADEMY BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ASU PREPARATORY ACADEMY BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ASU PREPARATORY ACADEMY BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ASU PREPARATORY ACADEMY BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ASU PREPARATORY ACADEMY BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: ASU PREPARATORY ACADEMY BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | First time form 5500 has been submitted | Yes |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BQH2 |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BQH2 | | Number of Individuals Covered | 752 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $15,251 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $285,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 11676 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18467/19099 |
| Policy instance | 3 |
| Insurance contract or identification number | 18467/19099 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,675 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 99077831001 |
| Policy instance | 2 |
| Insurance contract or identification number | 99077831001 | | Number of Individuals Covered | 983 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $8,728 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,728 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00022408 |
| Policy instance | 1 |
| Insurance contract or identification number | ER00022408 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $4,404 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $14,993 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,114 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00022408 |
| Policy instance | 1 |
| Insurance contract or identification number | ER00022408 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $3,723 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $20,485 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,492 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 99077831001 |
| Policy instance | 2 |
| Insurance contract or identification number | 99077831001 | | Number of Individuals Covered | 849 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $8,193 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,193 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18467/19099 |
| Policy instance | 3 |
| Insurance contract or identification number | 18467/19099 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BQH2 |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BQH2 | | Number of Individuals Covered | 706 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $11,676 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $123,366 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 11676 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00022408 |
| Policy instance | 1 |
| Insurance contract or identification number | ER00022408 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,593 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $12,275 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,028 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 99077831001 |
| Policy instance | 2 |
| Insurance contract or identification number | 99077831001 | | Number of Individuals Covered | 609 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $6,415 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,703 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,204 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18467/19099 |
| Policy instance | 3 |
| Insurance contract or identification number | 18467/19099 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $1,975 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,462 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 36484 00001 |
| Policy instance | 4 |
| Insurance contract or identification number | 36484 00001 | | Number of Individuals Covered | 346 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $18,361 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,492 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BQH2 |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0BQH2 | | Number of Individuals Covered | 579 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $7,741 | | Total amount of fees paid to insurance company | USD $3,449 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $84,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,709 | | Amount paid for insurance broker fees | 1370 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 36484 00001 |
| Policy instance | 5 |
| Insurance contract or identification number | 36484 00001 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $9,846 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $9,846 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18467/19099 |
| Policy instance | 4 |
| Insurance contract or identification number | 18467/19099 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $1,166 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,691 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,166 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 99077831001 |
| Policy instance | 3 |
| Insurance contract or identification number | 99077831001 | | Number of Individuals Covered | 338 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $6,135 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,935 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1044609 |
| Policy instance | 2 |
| Insurance contract or identification number | 1044609 | | Number of Individuals Covered | 424 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $6,282 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $79,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,282 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00022408 |
| Policy instance | 1 |
| Insurance contract or identification number | ER00022408 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $2,349 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $10,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,778 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 55755, 36484 |
| Policy instance | 3 |
| Insurance contract or identification number | 55755, 36484 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $10,714 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $143,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $10,714 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 99077831001 |
| Policy instance | 4 |
| Insurance contract or identification number | 99077831001 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $4,772 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,106 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,772 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18467/19099 |
| Policy instance | 5 |
| Insurance contract or identification number | 18467/19099 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $1,281 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,281 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1044609 |
| Policy instance | 2 |
| Insurance contract or identification number | 1044609 | | Number of Individuals Covered | 463 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $6,287 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $86,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,287 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00022408 |
| Policy instance | 1 |
| Insurance contract or identification number | ER00022408 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $4,730 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $12,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,727 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00022408 |
| Policy instance | 1 |
| Insurance contract or identification number | ER00022408 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,870 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $5,876 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1044609 |
| Policy instance | 2 |
| Insurance contract or identification number | 1044609 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $4,695 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $64,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 55755, 36484 |
| Policy instance | 3 |
| Insurance contract or identification number | 55755, 36484 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $9,029 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $113,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 99077831001 |
| Policy instance | 4 |
| Insurance contract or identification number | 99077831001 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $3,331 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,068 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18467, 19099 |
| Policy instance | 5 |
| Insurance contract or identification number | 18467, 19099 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,117 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,085 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 36484/55755 |
| Policy instance | 1 |
| Insurance contract or identification number | 36484/55755 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $4,410 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $59,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,998 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18467 |
| Policy instance | 2 |
| Insurance contract or identification number | 18467 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $878 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $878 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9907783 |
| Policy instance | 3 |
| Insurance contract or identification number | 9907783 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,277 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,361 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,277 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1044609 |
| Policy instance | 4 |
| Insurance contract or identification number | 1044609 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $3,457 | | Total amount of fees paid to insurance company | USD $117 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT, LEGAL EMPLOYEE ASSISTANCE PROGRAM | | 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 $40,999 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,457 | | Amount paid for insurance broker fees | 117 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | G000027307 |
| Policy instance | 5 |
| Insurance contract or identification number | G000027307 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $1,402 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT 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 $3,545 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $909 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 36484/55755 |
| Policy instance | 1 |
| Insurance contract or identification number | 36484/55755 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $4,842 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $55,754 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,842 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
| Policy contract number | 18467 |
| Policy instance | 2 |
| Insurance contract or identification number | 18467 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,028 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,279 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,028 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9907783 |
| Policy instance | 3 |
| Insurance contract or identification number | 9907783 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,978 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,489 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,978 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1044609 |
| Policy instance | 4 |
| Insurance contract or identification number | 1044609 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $2,902 | | Total amount of fees paid to insurance company | USD $2,351 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT, LEGAL EMPLOYEE ASSISTANCE PROGRAM | | 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 $33,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,683 | | Amount paid for insurance broker fees | 2351 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | G000027307 |
| Policy instance | 5 |
| Insurance contract or identification number | G000027307 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $783 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT 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 $1,748 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $622 | | Insurance broker organization code? | 3 | | Insurance broker name | PARAGON PARTNERS LIMITED |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 542806 |
| Policy instance | 1 |
| Insurance contract or identification number | 542806 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $7,386 | | Total amount of fees paid to insurance company | USD $1,769 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT CRITICAL ILLNESS, 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 $73,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,447 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1769 | | Additional information about fees paid to insurance broker | VOLUME INCENTIVES | | Insurance broker name | CREATIVE BENEFIT STRATEGIES |
|
| KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 ) |
| Policy contract number | 7209938000 |
| Policy instance | 2 |
| Insurance contract or identification number | 7209938000 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $377 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT CRITICAL ILLNESS, 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 $2,843 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $377 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD AND AGENCY |
|
| HEALTH NET OF AZ (National Association of Insurance Commissioners NAIC id number: 66141 ) |
| Policy contract number | A6321A/A6321B |
| Policy instance | 1 |
| Insurance contract or identification number | A6321A/A6321B | | Number of Individuals Covered | 128 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL EMPLOYEE ASSISTANCE PROGRAM | | 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 $321,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 542806 |
| Policy instance | 2 |
| Insurance contract or identification number | 542806 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $7,685 | | Total amount of fees paid to insurance company | USD $976 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT CRITICAL ILLNESS, 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 $71,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,685 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 976 | | Additional information about fees paid to insurance broker | VOLUME INCENTIVES | | Insurance broker name | CREATIVE BENEFIT STRATEGIES |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 542806 |
| Policy instance | 2 |
| Insurance contract or identification number | 542806 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $8,477 | | Total amount of fees paid to insurance company | USD $1,170 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT CRITICAL ILLNESS, 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 $60,547 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NET OF AZ (National Association of Insurance Commissioners NAIC id number: 66141 ) |
| Policy contract number | Z13500 |
| Policy instance | 1 |
| Insurance contract or identification number | Z13500 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $29,948 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL EMPLOYEE ASSISTANCE PROGRAM | | 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 $135,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
