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CALO WELFARE BENEFIT PLAN 401k Plan overview

Plan NameCALO WELFARE BENEFIT PLAN
Plan identification number 501

CALO WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

CHANGE ACADEMY AT LAKE OF THE OZARKS, LLC has sponsored the creation of one or more 401k plans.

Company Name:CHANGE ACADEMY AT LAKE OF THE OZARKS, LLC
Employer identification number (EIN):263297560
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about CHANGE ACADEMY AT LAKE OF THE OZARKS, LLC

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division
Incorporation Date: 2017-01-10
Company Identification Number: 128203296
Legal Registered Office Address: 160 SW SCALEHOUSE LOOP

BEND
United States of America (USA)
97702

More information about CHANGE ACADEMY AT LAKE OF THE OZARKS, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CALO WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01RYAN PENHALLEGON2023-07-12
5012021-01-01RYAN PENHALLEGON2022-06-27
5012020-01-01RYAN PENHALLEGON2021-10-06
5012019-09-01RYAN PENHALLEGON2020-09-25
5012018-09-01RYAN PENHALLEGON2020-06-15
5012017-09-01
5012016-09-01NORMUND VITOLS
5012015-09-01JOHN BOUDINOT
5012014-09-01ROGER K. TURNER

Plan Statistics for CALO WELFARE BENEFIT PLAN

401k plan membership statisitcs for CALO WELFARE BENEFIT PLAN

Measure Date Value
2022: CALO WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01905
Total number of active participants reported on line 7a of the Form 55002022-01-011,204
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-011,204
Number of employers contributing to the scheme2022-01-010
2021: CALO WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01547
Total number of active participants reported on line 7a of the Form 55002021-01-01547
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01547
Number of employers contributing to the scheme2021-01-010
2020: CALO WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01351
Total number of active participants reported on line 7a of the Form 55002020-01-01547
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01547
Number of employers contributing to the scheme2020-01-010
2019: CALO WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-01187
Total number of active participants reported on line 7a of the Form 55002019-09-01351
Number of retired or separated participants receiving benefits2019-09-010
Number of other retired or separated participants entitled to future benefits2019-09-010
Total of all active and inactive participants2019-09-01351
Number of employers contributing to the scheme2019-09-010
2018: CALO WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-09-01353
Total number of active participants reported on line 7a of the Form 55002018-09-01187
Number of retired or separated participants receiving benefits2018-09-010
Number of other retired or separated participants entitled to future benefits2018-09-010
Total of all active and inactive participants2018-09-01187
Number of employers contributing to the scheme2018-09-010
2017: CALO WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-09-01275
Total number of active participants reported on line 7a of the Form 55002017-09-01353
Number of retired or separated participants receiving benefits2017-09-015
Number of other retired or separated participants entitled to future benefits2017-09-010
Total of all active and inactive participants2017-09-01358
2016: CALO WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-09-01272
Total number of active participants reported on line 7a of the Form 55002016-09-01275
Number of retired or separated participants receiving benefits2016-09-010
Number of other retired or separated participants entitled to future benefits2016-09-010
Total of all active and inactive participants2016-09-01275
2015: CALO WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-09-01241
Total number of active participants reported on line 7a of the Form 55002015-09-01232
Number of retired or separated participants receiving benefits2015-09-010
Number of other retired or separated participants entitled to future benefits2015-09-010
Total of all active and inactive participants2015-09-01232
2014: CALO WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-09-01147
Total number of active participants reported on line 7a of the Form 55002014-09-01217
Number of retired or separated participants receiving benefits2014-09-011
Number of other retired or separated participants entitled to future benefits2014-09-010
Total of all active and inactive participants2014-09-01218

Form 5500 Responses for CALO WELFARE BENEFIT PLAN

2022: CALO WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: CALO WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: CALO WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: CALO WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan funding arrangement – General assets of the sponsorYes
2019-09-01Plan benefit arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – General assets of the sponsorYes
2018: CALO WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-09-01Type of plan entitySingle employer plan
2018-09-01Plan funding arrangement – InsuranceYes
2018-09-01Plan funding arrangement – General assets of the sponsorYes
2018-09-01Plan benefit arrangement – InsuranceYes
2018-09-01Plan benefit arrangement – General assets of the sponsorYes
2017: CALO WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01Submission has been amendedNo
2017-09-01This submission is the final filingNo
2017-09-01This return/report is a short plan year return/report (less than 12 months)No
2017-09-01Plan is a collectively bargained planNo
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan funding arrangement – General assets of the sponsorYes
2017-09-01Plan benefit arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – General assets of the sponsorYes
2016: CALO WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-09-01Type of plan entitySingle employer plan
2016-09-01Submission has been amendedNo
2016-09-01This submission is the final filingNo
2016-09-01This return/report is a short plan year return/report (less than 12 months)No
2016-09-01Plan is a collectively bargained planNo
2016-09-01Plan funding arrangement – InsuranceYes
2016-09-01Plan funding arrangement – General assets of the sponsorYes
2016-09-01Plan benefit arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – General assets of the sponsorYes
2015: CALO WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-09-01Type of plan entitySingle employer plan
2015-09-01Submission has been amendedNo
2015-09-01This submission is the final filingNo
2015-09-01This return/report is a short plan year return/report (less than 12 months)No
2015-09-01Plan is a collectively bargained planNo
2015-09-01Plan funding arrangement – InsuranceYes
2015-09-01Plan funding arrangement – General assets of the sponsorYes
2015-09-01Plan benefit arrangement – InsuranceYes
2015-09-01Plan benefit arrangement – General assets of the sponsorYes
2014: CALO WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-09-01Type of plan entitySingle employer plan
2014-09-01First time form 5500 has been submittedYes
2014-09-01Submission has been amendedNo
2014-09-01This submission is the final filingNo
2014-09-01This return/report is a short plan year return/report (less than 12 months)No
2014-09-01Plan is a collectively bargained planNo
2014-09-01Plan funding arrangement – InsuranceYes
2014-09-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX969445
Policy instance 2
Insurance contract or identification numberFLX969445
Number of Individuals Covered1204
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $17,249
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $177,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $15,568
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number296293
Policy instance 1
Insurance contract or identification number296293
Number of Individuals Covered51
Insurance policy start date2022-02-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $3,633
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $172,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,633
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK966260
Policy instance 1
Insurance contract or identification numberLK966260
Number of Individuals Covered547
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $14,702
Total amount of fees paid to insurance companyUSD $3,778
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $147,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $14,702
Amount paid for insurance broker fees3778
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX969445
Policy instance 2
Insurance contract or identification numberFLX969445
Number of Individuals Covered547
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10,295
Total amount of fees paid to insurance companyUSD $1,054
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $102,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $10,295
Amount paid for insurance broker fees1054
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number614923
Policy instance 1
Insurance contract or identification number614923
Number of Individuals Covered751
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $123,859
Total amount of fees paid to insurance companyUSD $1,008
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $586,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $123,937
Amount paid for insurance broker fees1008
Additional information about fees paid to insurance brokerINCENTIVE COMPENSATION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD606976
Policy instance 2
Insurance contract or identification numberSGD606976
Number of Individuals Covered351
Insurance policy start date2019-09-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $53,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905691
Policy instance 1
Insurance contract or identification number905691
Number of Individuals Covered825
Insurance policy start date2019-09-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,199
Total amount of fees paid to insurance companyUSD $20,415
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $660,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,199
Amount paid for insurance broker fees20043
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD606976
Policy instance 3
Insurance contract or identification numberSGD606976
Number of Individuals Covered187
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $14,997
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $126,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $13,127
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905691
Policy instance 1
Insurance contract or identification number905691
Number of Individuals Covered487
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $64,387
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,014,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees87
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number869591
Policy instance 2
Insurance contract or identification number869591
Number of Individuals Covered440
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $18,545
Total amount of fees paid to insurance companyUSD $17
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $179,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,545
Amount paid for insurance broker fees17
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSEE BELOW
Policy instance 3
Insurance contract or identification numberSEE BELOW
Number of Individuals Covered353
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $6,289
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $61,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0869591
Policy instance 2
Insurance contract or identification number0869591
Number of Individuals Covered397
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $13,147
Total amount of fees paid to insurance companyUSD $2,343
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 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 $138,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905691
Policy instance 1
Insurance contract or identification number905691
Number of Individuals Covered429
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $38,705
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 $1,376,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM606734
Policy instance 3
Insurance contract or identification numberSGM606734
Number of Individuals Covered232
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $6,164
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $61,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,164
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0869591
Policy instance 2
Insurance contract or identification number0869591
Number of Individuals Covered299
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $9,522
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 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 $103,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,522
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905691
Policy instance 1
Insurance contract or identification number905691
Number of Individuals Covered297
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $43,255
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,100,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees43255
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT AND BONUS
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number613268
Policy instance 1
Insurance contract or identification number613268
Number of Individuals Covered342
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $34,053
Total amount of fees paid to insurance companyUSD $734
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $920,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,106
Amount paid for insurance broker fees734
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameNAUGHT NAUGHT INSURANCE AGENCY

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