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HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameHCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN
Plan identification number 501

HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

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

Company Name:HCI SYSTEMS, INC.
Employer identification number (EIN):261656639
NAIC Classification:238900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-04-01
5012021-04-01
5012020-04-01
5012019-04-01
5012018-04-01
5012017-04-01DARIO CANIZALEZ
5012016-04-01DARIO CANIZALEZ
5012015-04-01DARIO CANIZALEZ
5012014-04-01DARIO CANIZALEZ

Plan Statistics for HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-04-01560
Total number of active participants reported on line 7a of the Form 55002022-04-01699
Number of retired or separated participants receiving benefits2022-04-014
Number of other retired or separated participants entitled to future benefits2022-04-010
Total of all active and inactive participants2022-04-01703
2021: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-04-01442
Total number of active participants reported on line 7a of the Form 55002021-04-01559
Number of retired or separated participants receiving benefits2021-04-011
Number of other retired or separated participants entitled to future benefits2021-04-010
Total of all active and inactive participants2021-04-01560
2020: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-04-01483
Total number of active participants reported on line 7a of the Form 55002020-04-01441
Number of retired or separated participants receiving benefits2020-04-011
Number of other retired or separated participants entitled to future benefits2020-04-010
Total of all active and inactive participants2020-04-01442
2019: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-04-01358
Total number of active participants reported on line 7a of the Form 55002019-04-01565
Number of retired or separated participants receiving benefits2019-04-012
Number of other retired or separated participants entitled to future benefits2019-04-010
Total of all active and inactive participants2019-04-01567
2018: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-04-01463
Total number of active participants reported on line 7a of the Form 55002018-04-01356
Number of retired or separated participants receiving benefits2018-04-012
Number of other retired or separated participants entitled to future benefits2018-04-010
Total of all active and inactive participants2018-04-01358
2017: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-01390
Total number of active participants reported on line 7a of the Form 55002017-04-01458
Number of retired or separated participants receiving benefits2017-04-015
Number of other retired or separated participants entitled to future benefits2017-04-010
Total of all active and inactive participants2017-04-01463
2016: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01369
Total number of active participants reported on line 7a of the Form 55002016-04-01390
Number of retired or separated participants receiving benefits2016-04-010
Number of other retired or separated participants entitled to future benefits2016-04-010
Total of all active and inactive participants2016-04-01390
2015: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01290
Total number of active participants reported on line 7a of the Form 55002015-04-01368
Number of retired or separated participants receiving benefits2015-04-011
Number of other retired or separated participants entitled to future benefits2015-04-010
Total of all active and inactive participants2015-04-01369
2014: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-04-01219
Total number of active participants reported on line 7a of the Form 55002014-04-01229
Number of retired or separated participants receiving benefits2014-04-010
Number of other retired or separated participants entitled to future benefits2014-04-010
Total of all active and inactive participants2014-04-01229

Form 5500 Responses for HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN

2022: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01Submission has been amendedNo
2022-04-01This submission is the final filingNo
2022-04-01This return/report is a short plan year return/report (less than 12 months)No
2022-04-01Plan is a collectively bargained planNo
2022-04-01Plan funding arrangement – InsuranceYes
2022-04-01Plan funding arrangement – General assets of the sponsorYes
2022-04-01Plan benefit arrangement – InsuranceYes
2022-04-01Plan benefit arrangement – General assets of the sponsorYes
2021: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Submission has been amendedNo
2021-04-01This submission is the final filingNo
2021-04-01This return/report is a short plan year return/report (less than 12 months)No
2021-04-01Plan is a collectively bargained planNo
2021-04-01Plan funding arrangement – InsuranceYes
2021-04-01Plan funding arrangement – General assets of the sponsorYes
2021-04-01Plan benefit arrangement – InsuranceYes
2021-04-01Plan benefit arrangement – General assets of the sponsorYes
2020: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Submission has been amendedNo
2020-04-01This submission is the final filingNo
2020-04-01This return/report is a short plan year return/report (less than 12 months)No
2020-04-01Plan is a collectively bargained planNo
2020-04-01Plan funding arrangement – InsuranceYes
2020-04-01Plan funding arrangement – General assets of the sponsorYes
2020-04-01Plan benefit arrangement – InsuranceYes
2020-04-01Plan benefit arrangement – General assets of the sponsorYes
2019: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Submission has been amendedNo
2019-04-01This submission is the final filingNo
2019-04-01This return/report is a short plan year return/report (less than 12 months)No
2019-04-01Plan is a collectively bargained planNo
2019-04-01Plan funding arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – InsuranceYes
2018: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Submission has been amendedNo
2018-04-01This submission is the final filingNo
2018-04-01This return/report is a short plan year return/report (less than 12 months)No
2018-04-01Plan is a collectively bargained planNo
2018-04-01Plan funding arrangement – InsuranceYes
2018-04-01Plan benefit arrangement – InsuranceYes
2017: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Submission has been amendedNo
2017-04-01This submission is the final filingNo
2017-04-01This return/report is a short plan year return/report (less than 12 months)No
2017-04-01Plan is a collectively bargained planNo
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – InsuranceYes
2016: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – InsuranceYes
2015: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – InsuranceYes
2014: HCI SYSTEMS, INC EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01First time form 5500 has been submittedYes
2014-04-01Submission has been amendedNo
2014-04-01This submission is the final filingNo
2014-04-01This return/report is a short plan year return/report (less than 12 months)No
2014-04-01Plan is a collectively bargained planNo
2014-04-01Plan funding arrangement – General assets of the sponsorYes
2014-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B5WT
Policy instance 6
Insurance contract or identification numberGUC0B5WT
Number of Individuals Covered81
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $13,784
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $68,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,784
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B5WT
Policy instance 5
Insurance contract or identification numberGVTL0B5WT
Number of Individuals Covered219
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $25,917
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $129,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,917
Insurance broker organization code?3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0176591HNO
Policy instance 4
Insurance contract or identification number0176591HNO
Number of Individuals Covered702
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $100,036
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,233,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $100,036
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0176591
Policy instance 3
Insurance contract or identification number0176591
Number of Individuals Covered832
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $39,468
Total amount of fees paid to insurance companyUSD $7,660
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $834,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,468
Amount paid for insurance broker fees7660
Additional information about fees paid to insurance broker2022 Q2 SIGNATURE MEDICAL NEW BUSINESS INCENTIVE RISK
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B5WT
Policy instance 2
Insurance contract or identification numberGUDH0B5WT
Number of Individuals Covered120
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $4,118
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $27,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,118
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B5WT
Policy instance 1
Insurance contract or identification numberGUDE0B5WT
Number of Individuals Covered90
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $2,932
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL 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 CarrierUSD $19,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,932
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B5WT
Policy instance 1
Insurance contract or identification numberGUDE0B5WT
Number of Individuals Covered88
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $2,685
Total amount of fees paid to insurance companyUSD $1,168
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL 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 CarrierUSD $17,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,235
Amount paid for insurance broker fees1168
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B5WT
Policy instance 2
Insurance contract or identification numberGUC0B5WT
Number of Individuals Covered60
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $10,790
Total amount of fees paid to insurance companyUSD $3,397
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $53,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,954
Amount paid for insurance broker fees3397
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDB0B5WT
Policy instance 3
Insurance contract or identification numberGUDB0B5WT
Number of Individuals Covered376
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $41,893
Total amount of fees paid to insurance companyUSD $8,750
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $279,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,955
Amount paid for insurance broker fees8750
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B5WT
Policy instance 4
Insurance contract or identification numberGVTL0B5WT
Number of Individuals Covered189
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $21,715
Total amount of fees paid to insurance companyUSD $6,931
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $108,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,086
Amount paid for insurance broker fees6931
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLLV0B5WT
Policy instance 5
Insurance contract or identification numberGLLV0B5WT
Number of Individuals Covered334
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $6,420
Total amount of fees paid to insurance companyUSD $2,922
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $42,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,392
Amount paid for insurance broker fees2922
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B5WT
Policy instance 6
Insurance contract or identification numberGUDH0B5WT
Number of Individuals Covered127
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $3,881
Total amount of fees paid to insurance companyUSD $1,645
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,227
Amount paid for insurance broker fees1645
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B5WT
Policy instance 6
Insurance contract or identification numberGUDE0B5WT
Number of Individuals Covered92
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $2,704
Total amount of fees paid to insurance companyUSD $1,156
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL 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 CarrierUSD $18,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,704
Amount paid for insurance broker fees1156
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B5WT
Policy instance 5
Insurance contract or identification numberGUDH0B5WT
Number of Individuals Covered117
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $3,761
Total amount of fees paid to insurance companyUSD $1,733
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT ONLY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,761
Amount paid for insurance broker fees1733
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B5WT
Policy instance 4
Insurance contract or identification numberGUC0B5WT
Number of Individuals Covered57
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $10,551
Total amount of fees paid to insurance companyUSD $3,592
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $52,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,551
Amount paid for insurance broker fees3592
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B5WT
Policy instance 3
Insurance contract or identification numberGVTL0B5WT
Number of Individuals Covered192
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $20,963
Total amount of fees paid to insurance companyUSD $7,163
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $104,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,963
Amount paid for insurance broker fees7163
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLLV0B5WT
Policy instance 2
Insurance contract or identification numberGLLV0B5WT
Number of Individuals Covered340
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $7,162
Total amount of fees paid to insurance companyUSD $2,604
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $47,750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,162
Amount paid for insurance broker fees2604
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDB0B5WT
Policy instance 1
Insurance contract or identification numberGUDB0B5WT
Number of Individuals Covered347
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $43,396
Total amount of fees paid to insurance companyUSD $6,562
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $289,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,396
Amount paid for insurance broker fees6562
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B5WT
Policy instance 3
Insurance contract or identification numberGUDE0B5WT
Number of Individuals Covered73
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $1,504
Total amount of fees paid to insurance companyUSD $765
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL 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 CarrierUSD $10,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,504
Amount paid for insurance broker fees765
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911070
Policy instance 1
Insurance contract or identification number911070
Number of Individuals Covered901
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $149,290
Total amount of fees paid to insurance companyUSD $12,105
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,728,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $149,290
Insurance broker organization code?3
Amount paid for insurance broker fees12105
Additional information about fees paid to insurance brokerBONUS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B5WT
Policy instance 2
Insurance contract or identification numberGUDH0B5WT
Number of Individuals Covered121
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $3,340
Total amount of fees paid to insurance companyUSD $1,601
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT ONLY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,340
Amount paid for insurance broker fees1601
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B5WT
Policy instance 4
Insurance contract or identification numberGUC0B5WT
Number of Individuals Covered58
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $9,124
Total amount of fees paid to insurance companyUSD $3,176
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $45,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,124
Amount paid for insurance broker fees3176
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B5WT
Policy instance 5
Insurance contract or identification numberGVTL0B5WT
Number of Individuals Covered212
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $18,633
Total amount of fees paid to insurance companyUSD $6,980
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $93,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,633
Amount paid for insurance broker fees6980
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B5WT
Policy instance 7
Insurance contract or identification numberGVTL0B5WT
Number of Individuals Covered204
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $17,892
Total amount of fees paid to insurance companyUSD $5,213
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $89,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,892
Amount paid for insurance broker fees5213
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911070
Policy instance 1
Insurance contract or identification number911070
Number of Individuals Covered676
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $104,067
Total amount of fees paid to insurance companyUSD $18,995
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,758,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $104,067
Insurance broker organization code?3
Amount paid for insurance broker fees18995
Additional information about fees paid to insurance brokerBONUS
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number281194
Policy instance 2
Insurance contract or identification number281194
Number of Individuals Covered660
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $18,284
Total amount of fees paid to insurance companyUSD $8,451
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $200,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,892
Amount paid for insurance broker fees8451
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30039645
Policy instance 3
Insurance contract or identification number30039645
Number of Individuals Covered286
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $3,984
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,984
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B5WT
Policy instance 4
Insurance contract or identification numberGUDH0B5WT
Number of Individuals Covered98
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $2,788
Total amount of fees paid to insurance companyUSD $1,500
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT ONLY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,788
Amount paid for insurance broker fees1500
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B5WT
Policy instance 5
Insurance contract or identification numberGUDE0B5WT
Number of Individuals Covered50
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $1,760
Total amount of fees paid to insurance companyUSD $949
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL 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 CarrierUSD $11,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,760
Amount paid for insurance broker fees949
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B5WT
Policy instance 6
Insurance contract or identification numberGUC0B5WT
Number of Individuals Covered44
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $5,819
Total amount of fees paid to insurance companyUSD $1,388
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,819
Amount paid for insurance broker fees1388
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number281194
Policy instance 2
Insurance contract or identification number281194
Number of Individuals Covered575
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $13,843
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $144,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,843
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE, INC.
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1042587
Policy instance 3
Insurance contract or identification number1042587
Number of Individuals Covered301
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $10,931
Total amount of fees paid to insurance companyUSD $1,001
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $72,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,931
Amount paid for insurance broker fees1001
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30039645
Policy instance 4
Insurance contract or identification number30039645
Number of Individuals Covered267
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $3,552
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,552
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B5WT
Policy instance 5
Insurance contract or identification numberG000B5WT
Number of Individuals Covered65
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $1,819
Total amount of fees paid to insurance companyUSD $616
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,819
Amount paid for insurance broker fees616
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B5WT
Policy instance 6
Insurance contract or identification numberG000B5WT
Number of Individuals Covered41
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $1,102
Total amount of fees paid to insurance companyUSD $446
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL 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 CarrierUSD $7,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,102
Amount paid for insurance broker fees446
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911070
Policy instance 1
Insurance contract or identification number911070
Number of Individuals Covered595
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $76,349
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,400,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $76,349
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE, INC.

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