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MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 401k Plan overview

Plan NameMIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
Plan identification number 510

MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) Benefits

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

401k Sponsoring company profile

MIDWEST MEMORIAL GROUP, LLC has sponsored the creation of one or more 401k plans.

Company Name:MIDWEST MEMORIAL GROUP, LLC
Employer identification number (EIN):260885160
NAIC Classification:812220
NAIC Description:Cemeteries and Crematories

Additional information about MIDWEST MEMORIAL GROUP, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 4420262

More information about MIDWEST MEMORIAL GROUP, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5102017-01-01
5102016-01-01
5102015-01-01
5102014-01-01
5102013-01-01
5102012-01-01DONNA CAMPBELL
5102011-01-01DONNA CAMPBELL

Plan Statistics for MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

401k plan membership statisitcs for MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

Measure Date Value
2017: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2017 401k membership
Total participants, beginning-of-year2017-01-01282
Total number of active participants reported on line 7a of the Form 55002017-01-01279
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01279
2016: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2016 401k membership
Total participants, beginning-of-year2016-01-01323
Total number of active participants reported on line 7a of the Form 55002016-01-01283
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01283
2015: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2015 401k membership
Total participants, beginning-of-year2015-01-01205
Number of retired or separated participants receiving benefits2015-01-01211
Total of all active and inactive participants2015-01-01211
2014: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2014 401k membership
Total participants, beginning-of-year2014-01-01213
Total number of active participants reported on line 7a of the Form 55002014-01-01205
Total of all active and inactive participants2014-01-01205
2013: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2013 401k membership
Total participants, beginning-of-year2013-01-01190
Total number of active participants reported on line 7a of the Form 55002013-01-01213
Total of all active and inactive participants2013-01-01213
2012: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2012 401k membership
Total participants, beginning-of-year2012-01-01173
Total number of active participants reported on line 7a of the Form 55002012-01-01190
Total of all active and inactive participants2012-01-01190
2011: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2011 401k membership
Total participants, beginning-of-year2011-01-01174
Total number of active participants reported on line 7a of the Form 55002011-01-01173
Number of retired or separated participants receiving benefits2011-01-010
Total of all active and inactive participants2011-01-01173

Financial Data on MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

Measure Date Value
2015 : MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2015 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2015-12-31No
Was this plan covered by a fidelity bond2015-12-31No
If this is an individual account plan, was there a blackout period2015-12-31No
Were there any nonexempt tranactions with any party-in-interest2015-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2015-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2015-12-31No
Were any leases to which the plan was party in default or uncollectible2015-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2015-12-31No
Was there a failure to transmit to the plan any participant contributions2015-12-31No
Has the plan failed to provide any benefit when due under the plan2015-12-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32015-12-31No
Did the plan have assets held for investment2015-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2015-12-31No
2014 : MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2014 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2014-12-31No
Was this plan covered by a fidelity bond2014-12-31No
If this is an individual account plan, was there a blackout period2014-12-31No
Were there any nonexempt tranactions with any party-in-interest2014-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2014-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2014-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2014-12-31No
Were any leases to which the plan was party in default or uncollectible2014-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2014-12-31No
Was there a failure to transmit to the plan any participant contributions2014-12-31No
Has the plan failed to provide any benefit when due under the plan2014-12-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32014-12-31No
Did the plan have assets held for investment2014-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2014-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2014-12-31No

Form 5500 Responses for MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

2017: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: MIDWEST MEMORIAL GROUP, LLC HEALTH REIMBURSEMENT ARRANGEMENT (HRA) 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0AWXY
Policy instance 3
Insurance contract or identification numberGUG0AWXY
Number of Individuals Covered279
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $6,350
Total amount of fees paid to insurance companyUSD $3,797
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $63,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,350
Amount paid for insurance broker fees3797
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS SVCES INC
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00100020
Policy instance 2
Insurance contract or identification number00100020
Number of Individuals Covered272
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $42,177
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,126,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $42,177
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUNKNOWN
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number37615
Policy instance 1
Insurance contract or identification number37615
Number of Individuals Covered366
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5976
Policy instance 2
Insurance contract or identification number5976
Number of Individuals Covered396
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,411
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $111,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,411
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number37615
Policy instance 1
Insurance contract or identification number37615
Number of Individuals Covered399
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $51,550
Total amount of fees paid to insurance companyUSD $2,501
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,348,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,208
Insurance broker organization code?3
Amount paid for insurance broker fees1908
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker nameAUSTIN FINANCIAL GROUP LLC
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5976
Policy instance 2
Insurance contract or identification number5976
Number of Individuals Covered413
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,954
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $98,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,954
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30034057
Policy instance 3
Insurance contract or identification number30034057
Number of Individuals Covered204
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $1,166
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,166
Additional information about fees paid to insurance brokerADMINISTRATIVE FEE
Insurance broker organization code?4
Insurance broker nameHANTZ BENEFIT SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALPZ
Policy instance 5
Insurance contract or identification numberG000ALPZ
Number of Individuals Covered57
Insurance policy start date2013-07-01
Insurance policy end date2014-07-01
Total amount of commissions paid to insurance brokerUSD $1,174
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,174
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALPZ
Policy instance 4
Insurance contract or identification numberG000ALPZ
Number of Individuals Covered283
Insurance policy start date2013-07-01
Insurance policy end date2014-07-01
Total amount of commissions paid to insurance brokerUSD $2,082
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $20,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,082
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALPZ
Policy instance 6
Insurance contract or identification numberG000ALPZ
Number of Individuals Covered72
Insurance policy start date2013-07-01
Insurance policy end date2014-07-01
Total amount of commissions paid to insurance brokerUSD $2,449
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedVOLUNTARY SHORT-TERM DISABILITY
Welfare Benefit Premiums Paid to CarrierUSD $24,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,449
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number37615
Policy instance 1
Insurance contract or identification number37615
Number of Individuals Covered379
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $39,080
Total amount of fees paid to insurance companyUSD $8,092
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,718,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,080
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker nameHANTZ BENEFIT SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALPZ
Policy instance 6
Insurance contract or identification numberG000ALPZ
Number of Individuals Covered71
Insurance policy start date2012-07-01
Insurance policy end date2013-07-01
Total amount of commissions paid to insurance brokerUSD $2,600
Total amount of fees paid to insurance companyUSD $393
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedVOLUNTARY SHORT-TERM DISABILITY
Welfare Benefit Premiums Paid to CarrierUSD $25,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,600
Amount paid for insurance broker fees393
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker nameHANTZ BENEFIT SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALPZ
Policy instance 5
Insurance contract or identification numberG000ALPZ
Number of Individuals Covered59
Insurance policy start date2012-07-01
Insurance policy end date2013-07-01
Total amount of commissions paid to insurance brokerUSD $1,230
Total amount of fees paid to insurance companyUSD $153
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,230
Amount paid for insurance broker fees153
Additional information about fees paid to insurance brokerSERVICE FEE
Insurance broker nameHANTZ BENEFIT SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALPZ
Policy instance 4
Insurance contract or identification numberG000ALPZ
Number of Individuals Covered278
Insurance policy start date2012-07-01
Insurance policy end date2013-07-01
Total amount of commissions paid to insurance brokerUSD $2,044
Total amount of fees paid to insurance companyUSD $249
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $20,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,044
Amount paid for insurance broker fees249
Additional information about fees paid to insurance brokerSERVICE FEE
Insurance broker nameHANTZ BENEFIT SERVICES LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30034057
Policy instance 3
Insurance contract or identification number30034057
Number of Individuals Covered190
Insurance policy start date2013-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $1,072
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,072
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerADMINISTRATIVE FEE
Insurance broker nameHANTZ BENEFIT SERVICES LLC
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5976
Policy instance 2
Insurance contract or identification number5976
Number of Individuals Covered393
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $4,580
Total amount of fees paid to insurance companyUSD $13,966
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $95,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,580
Amount paid for insurance broker fees13966
Additional information about fees paid to insurance brokerADMIN SERVICE FEE
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number37615
Policy instance 1
Insurance contract or identification number37615
Number of Individuals Covered364
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $50,024
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,547,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,955
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number150995
Policy instance 2
Insurance contract or identification number150995
Number of Individuals Covered84
Insurance policy start date2011-07-01
Insurance policy end date2012-07-01
Total amount of commissions paid to insurance brokerUSD $2,501
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,501
Additional information about fees paid to insurance brokerINSURANCE COMMISSION
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number905751
Policy instance 3
Insurance contract or identification number905751
Number of Individuals Covered284
Insurance policy start date2011-07-01
Insurance policy end date2012-07-01
Total amount of commissions paid to insurance brokerUSD $3,356
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $29,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,356
Additional information about fees paid to insurance brokerINSURANCE COMMISSIONS
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5976
Policy instance 4
Insurance contract or identification number5976
Number of Individuals Covered345
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $4,606
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $97,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,606
Additional information about fees paid to insurance brokerINSURANCE COMMISSIONS
Insurance broker organization code?3
Insurance broker nameHANTZ BENEFIT SERVICES LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30034057
Policy instance 5
Insurance contract or identification number30034057
Number of Individuals Covered191
Insurance policy start date2012-07-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $523
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $523
Additional information about fees paid to insurance brokerINSURANCE COMMISIONS
Insurance broker nameHANTZ BENEFIT SERVICES LLC
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5976
Policy instance 6
Insurance contract or identification number5976
Number of Individuals Covered343
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $977
Total amount of fees paid to insurance companyUSD $4,804
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $977
Amount paid for insurance broker fees4804
Additional information about fees paid to insurance brokerADMINISTRATION AND OTHER FEES
Insurance broker nameHANTZ BENEFIT SERVICES LLC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number37615
Policy instance 1
Insurance contract or identification number37615
Number of Individuals Covered359
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $33,367
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,751,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,385
Additional information about fees paid to insurance brokerCOMMISSION AND INCENTIVE PAYMENTS
Insurance broker organization code?3
Insurance broker nameKATHRYN T DELAND
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number37615
Policy instance 1
Insurance contract or identification number37615
Number of Individuals Covered329
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $39,771
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,762,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number150995
Policy instance 2
Insurance contract or identification number150995
Number of Individuals Covered84
Insurance policy start date2010-07-01
Insurance policy end date2011-07-01
Total amount of commissions paid to insurance brokerUSD $2,483
Total amount of fees paid to insurance companyUSD $196
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number905751
Policy instance 3
Insurance contract or identification number905751
Number of Individuals Covered284
Insurance policy start date2010-07-01
Insurance policy end date2011-07-01
Total amount of commissions paid to insurance brokerUSD $3,207
Total amount of fees paid to insurance companyUSD $219
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $32,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5976
Policy instance 4
Insurance contract or identification number5976
Number of Individuals Covered332
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $4,696
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $97,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5976
Policy instance 5
Insurance contract or identification number5976
Number of Individuals Covered333
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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