BLACK FOREST VENTURES, LLC has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022: BLACK FOREST VENTURES, LLC 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 208 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 201 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 201 |
| Number of employers contributing to the scheme | 2022-07-01 | 0 |
| 2021: BLACK FOREST VENTURES, LLC 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 196 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 208 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 208 |
| Number of employers contributing to the scheme | 2021-07-01 | 0 |
| 2020: BLACK FOREST VENTURES, LLC 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 186 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 196 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 196 |
| Number of employers contributing to the scheme | 2020-07-01 | 0 |
| 2019: BLACK FOREST VENTURES, LLC 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 397 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 183 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 13 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 196 |
| Number of employers contributing to the scheme | 2019-07-01 | 0 |
| 2018: BLACK FOREST VENTURES, LLC 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 465 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 393 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 397 |
| Number of employers contributing to the scheme | 2018-07-01 | 0 |
| 2017: BLACK FOREST VENTURES, LLC 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 445 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 465 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 0 |
| Total of all active and inactive participants | 2017-07-01 | 465 |
| 2016: BLACK FOREST VENTURES, LLC 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 222 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 188 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 0 |
| Total of all active and inactive participants | 2016-07-01 | 188 |
| 2015: BLACK FOREST VENTURES, LLC 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 209 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 0 |
| Total of all active and inactive participants | 2015-07-01 | 209 |
| 2022: BLACK FOREST VENTURES, LLC 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: BLACK FOREST VENTURES, LLC 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: BLACK FOREST VENTURES, LLC 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: BLACK FOREST VENTURES, LLC 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: BLACK FOREST VENTURES, LLC 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: BLACK FOREST VENTURES, LLC 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: BLACK FOREST VENTURES, LLC 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: BLACK FOREST VENTURES, LLC 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | First time form 5500 has been submitted | Yes |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BKD5 |
| Policy instance | 2 |
| Insurance contract or identification number | GVTL0BKD5 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $43,415 | | Total amount of fees paid to insurance company | USD $21,482 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $299,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,415 | | Amount paid for insurance broker fees | 21482 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 953640 |
| Policy instance | 1 |
| Insurance contract or identification number | 953640 | | Number of Individuals Covered | 281 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $23,810 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $224,342 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,810 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BKD5 |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0BKD5 | | Number of Individuals Covered | 209 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $33,573 | | Total amount of fees paid to insurance company | USD $18,424 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $232,466 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,573 | | Amount paid for insurance broker fees | 18424 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05959083 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05959083 | | Number of Individuals Covered | 574 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $14,330 | | Total amount of fees paid to insurance company | USD $57 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $179,268 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,330 | | Amount paid for insurance broker fees | 57 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10010921001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10010921001 | | Number of Individuals Covered | 397 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $4,600 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,600 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05959083 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05959083 | | Number of Individuals Covered | 648 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $16,090 | | Total amount of fees paid to insurance company | USD $1,168 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $159,052 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,090 | | Amount paid for insurance broker fees | 1168 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BKD5 |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0BKD5 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $30,038 | | Total amount of fees paid to insurance company | USD $14,756 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $210,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,038 | | Amount paid for insurance broker fees | 14756 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10010921001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10010921001 | | Number of Individuals Covered | 393 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $4,330 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,694 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,330 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10010921001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10010921001 | | Number of Individuals Covered | 353 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $3,411 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,306 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,411 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05959083 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05959083 | | Number of Individuals Covered | 584 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $17,004 | | Total amount of fees paid to insurance company | USD $2,166 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $183,038 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,004 | | Amount paid for insurance broker fees | 2166 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BKD5 |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0BKD5 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $29,891 | | Total amount of fees paid to insurance company | USD $4,481 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $205,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,891 | | Amount paid for insurance broker fees | 4481 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B6XC |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0B6XC | | Number of Individuals Covered | 91 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $13,858 | | Total amount of fees paid to insurance company | USD $7,981 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $101,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,858 | | Amount paid for insurance broker fees | 7981 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION , | | Insurance broker organization code? | 3 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5476748 |
| Policy instance | 2 |
| Insurance contract or identification number | 5476748 | | Number of Individuals Covered | 273 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $22,643 | | Total amount of fees paid to insurance company | USD $6,077 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $281,085 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,643 | | Amount paid for insurance broker fees | 6077 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10010921001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10010921001 | | Number of Individuals Covered | 397 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $2,355 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,355 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0B6XC |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0B6XC | | Number of Individuals Covered | 83 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $10,221 | | Total amount of fees paid to insurance company | USD $1,764 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $68,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,221 | | Amount paid for insurance broker fees | 1764 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 1001092 |
| Policy instance | 2 |
| Insurance contract or identification number | 1001092 | | Number of Individuals Covered | 389 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,879 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,569 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,879 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5476748 |
| Policy instance | 1 |
| Insurance contract or identification number | 5476748 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $21,908 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $266,555 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,908 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI SOUTHWEST, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 1001092 |
| Policy instance | 3 |
| Insurance contract or identification number | 1001092 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,104 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,260 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,104 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905375 |
| Policy instance | 2 |
| Insurance contract or identification number | 905375 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $65,407 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,167,471 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 65407 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5476748 |
| Policy instance | 1 |
| Insurance contract or identification number | 5476748 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $24,697 | | Total amount of fees paid to insurance company | USD $8,276 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $186,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,697 | | Amount paid for insurance broker fees | 8276 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION PRODUCER BONUS PROGRAM | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
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