ENVISION MEDICAL GROUP, PLLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2021: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-04-01 | 198 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-04-01 | 0 |
| Number of retired or separated participants receiving benefits | 2021-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-04-01 | 0 |
| Total of all active and inactive participants | 2021-04-01 | 0 |
| 2020: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-04-01 | 200 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-04-01 | 196 |
| Number of retired or separated participants receiving benefits | 2020-04-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2020-04-01 | 0 |
| Total of all active and inactive participants | 2020-04-01 | 198 |
| 2019: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-04-01 | 185 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-04-01 | 199 |
| Number of retired or separated participants receiving benefits | 2019-04-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-04-01 | 0 |
| Total of all active and inactive participants | 2019-04-01 | 200 |
| 2018: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-04-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-04-01 | 185 |
| Number of retired or separated participants receiving benefits | 2018-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-04-01 | 0 |
| Total of all active and inactive participants | 2018-04-01 | 185 |
| 2017: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-04-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-04-01 | 193 |
| Number of retired or separated participants receiving benefits | 2017-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-04-01 | 0 |
| Total of all active and inactive participants | 2017-04-01 | 193 |
| 2016: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-04-01 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-04-01 | 152 |
| Number of retired or separated participants receiving benefits | 2016-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-04-01 | 0 |
| Total of all active and inactive participants | 2016-04-01 | 152 |
| 2015: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-04-01 | 177 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-04-01 | 185 |
| Number of retired or separated participants receiving benefits | 2015-04-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-04-01 | 0 |
| Total of all active and inactive participants | 2015-04-01 | 187 |
| 2014: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-04-01 | 145 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-04-01 | 175 |
| Number of retired or separated participants receiving benefits | 2014-04-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-04-01 | 0 |
| Total of all active and inactive participants | 2014-04-01 | 177 |
| 2013: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-04-01 | 133 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-04-01 | 135 |
| Number of retired or separated participants receiving benefits | 2013-04-01 | 10 |
| Total of all active and inactive participants | 2013-04-01 | 145 |
| 2012: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-04-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-04-01 | 133 |
| Total of all active and inactive participants | 2012-04-01 | 133 |
| 2021: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-04-01 | Type of plan entity | Single employer plan |
| 2021-04-01 | This submission is the final filing | Yes |
| 2021-04-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2021-04-01 | Plan funding arrangement – Insurance | Yes |
| 2021-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-04-01 | Type of plan entity | Single employer plan |
| 2020-04-01 | Plan funding arrangement – Insurance | Yes |
| 2020-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-04-01 | Type of plan entity | Single employer plan |
| 2019-04-01 | Plan funding arrangement – Insurance | Yes |
| 2019-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-04-01 | Type of plan entity | Single employer plan |
| 2018-04-01 | Plan funding arrangement – Insurance | Yes |
| 2018-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-04-01 | Type of plan entity | Single employer plan |
| 2017-04-01 | Plan funding arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ENVISION MEDICAL GROUP PLLC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | First time form 5500 has been submitted | Yes |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| SIRIUS AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 35408 ) |
| Policy contract number | CMG-01508-19 |
| Policy instance | 3 |
| Insurance contract or identification number | CMG-01508-19 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $35,883 | | Welfare Benefit Premiums Paid to Carrier | USD $276,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,883 | | Additional information about fees paid to insurance broker | PLACEMENT OF STOP-LOSS INSURANCE | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000294372 |
| Policy instance | 2 |
| Insurance contract or identification number | 000000294372 | | Number of Individuals Covered | 173 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-05-01 | | Total amount of commissions paid to insurance broker | USD $6,883 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $35,396 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,883 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $18,291 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $174,296 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,291 | | Insurance broker organization code? | 3 |
|
| SIRIUS AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 35408 ) |
| Policy contract number | CMG-01508-19 |
| Policy instance | 3 |
| Insurance contract or identification number | CMG-01508-19 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $45,959 | | Welfare Benefit Premiums Paid to Carrier | USD $353,531 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,959 | | Additional information about fees paid to insurance broker | PLACEMENT OF STOP-LOSS INSURANCE | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000294372 |
| Policy instance | 2 |
| Insurance contract or identification number | 000000294372 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-05-01 | | Total amount of commissions paid to insurance broker | USD $5,998 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $29,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,998 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $27,215 | | Total amount of fees paid to insurance company | USD $7,580 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $267,617 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,215 | | Amount paid for insurance broker fees | 7580 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $28,794 | | Total amount of fees paid to insurance company | USD $7,715 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $277,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,794 | | Amount paid for insurance broker fees | 7715 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000294372 |
| Policy instance | 2 |
| Insurance contract or identification number | 000000294372 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-05-01 | | Total amount of commissions paid to insurance broker | USD $6,323 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $29,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,323 | | Insurance broker organization code? | 3 |
|
| SIRIUS AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 35408 ) |
| Policy contract number | CMG-01508-18 |
| Policy instance | 3 |
| Insurance contract or identification number | CMG-01508-18 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $42,481 | | Welfare Benefit Premiums Paid to Carrier | USD $326,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,481 | | Additional information about fees paid to insurance broker | PLACEMENT OF STOP-LOSS INSURANCE | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $26,278 | | Total amount of fees paid to insurance company | USD $9,172 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $254,275 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,278 | | Amount paid for insurance broker fees | 9172 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000294372 |
| Policy instance | 2 |
| Insurance contract or identification number | 000000294372 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-05-01 | | Total amount of commissions paid to insurance broker | USD $6,761 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $36,318 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,761 | | Insurance broker organization code? | 3 |
|
| SIRIUS AMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 35408 ) |
| Policy contract number | CMG-01508-18 |
| Policy instance | 3 |
| Insurance contract or identification number | CMG-01508-18 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $32,111 | | Welfare Benefit Premiums Paid to Carrier | USD $247,010 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,111 | | Additional information about fees paid to insurance broker | PLACEMENT OF STOP-LOSS INSURANCE | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 294372 |
| Policy instance | 4 |
| Insurance contract or identification number | 294372 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2016-05-01 | | Insurance policy end date | 2017-05-01 | | Total amount of commissions paid to insurance broker | USD $7,044 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $33,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,044 | | Insurance broker organization code? | 3 | | Insurance broker name | JS CLARK AGENCY INC |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 415141 |
| Policy instance | 3 |
| Insurance contract or identification number | 415141 | | Number of Individuals Covered | 253 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $28,173 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,173 | | Insurance broker organization code? | 3 | | Insurance broker name | PAUL KAHLER |
|
| EMPLOYEE HEALTH INSURANCE MANAGEMENT (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50001464-01 |
| Policy instance | 2 |
| Insurance contract or identification number | 50001464-01 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $1,966 | | Total amount of fees paid to insurance company | USD $9,797 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 9797 | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $1,966 | | Insurance broker name | J S CLARK AGENCY INC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $27,119 | | Total amount of fees paid to insurance company | USD $10,820 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $263,041 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,119 | | Amount paid for insurance broker fees | 10820 | | Insurance broker organization code? | 3 | | Insurance broker name | J S CLARK AGENCY INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 294372 |
| Policy instance | 4 |
| Insurance contract or identification number | 294372 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-05-01 | | Total amount of commissions paid to insurance broker | USD $6,852 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $32,614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,852 | | Insurance broker organization code? | 3 | | Insurance broker name | JS CLARK AGENCY INC |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | GROUP 45777 |
| Policy instance | 3 |
| Insurance contract or identification number | GROUP 45777 | | Number of Individuals Covered | 245 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $35,090 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,535 | | Insurance broker organization code? | 3 | | Insurance broker name | J.S. CLARK AGENCY |
|
| EMPLOYEE HEALTH INSURANCE MANAGEMENT (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50001464-01 |
| Policy instance | 2 |
| Insurance contract or identification number | 50001464-01 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $1,468 | | Total amount of fees paid to insurance company | USD $7,360 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 7360 | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $1,468 | | Insurance broker name | J S CLARK AGENCY INC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $25,056 | | Total amount of fees paid to insurance company | USD $10,286 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $243,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,056 | | Amount paid for insurance broker fees | 10286 | | Insurance broker organization code? | 3 | | Insurance broker name | J S CLARK AGENCY INC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $19,625 | | Total amount of fees paid to insurance company | USD $8,812 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $190,549 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,625 | | Amount paid for insurance broker fees | 8812 | | Insurance broker organization code? | 3 | | Insurance broker name | J S CLARK AGENCY INC |
|
| EMPLOYEE HEALTH INSURANCE MANAGEMENT (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50001464-01 |
| Policy instance | 2 |
| Insurance contract or identification number | 50001464-01 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $1,266 | | Total amount of fees paid to insurance company | USD $4,393 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4393 | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $1,266 | | Insurance broker name | J S CLARK AGENCY INC |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | GROUP 45777 |
| Policy instance | 3 |
| Insurance contract or identification number | GROUP 45777 | | Number of Individuals Covered | 244 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $43,791 | | Total amount of fees paid to insurance company | USD $3,784 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,915 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3784 | | Insurance broker name | J.S. CLARK AGENCY |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000294372 |
| Policy instance | 4 |
| Insurance contract or identification number | 000000294372 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-05-01 | | Total amount of commissions paid to insurance broker | USD $7,083 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $34,660 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,083 | | Insurance broker organization code? | 3 | | Insurance broker name | JS CLARK AGENCY INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000294372 |
| Policy instance | 4 |
| Insurance contract or identification number | 000000294372 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-05-01 | | Total amount of commissions paid to insurance broker | USD $5,822 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $29,514 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,822 | | Insurance broker organization code? | 3 | | Insurance broker name | JS CLARK AGENCY INC |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | CID 415141 |
| Policy instance | 3 |
| Insurance contract or identification number | CID 415141 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $41,600 | | Total amount of fees paid to insurance company | USD $3,364 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,505 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3364 | | Insurance broker name | ACTION BENEFITS COMPANY |
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| EMPLOYEE HEALTH INSURANCE MANAGEMENT (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50001464-01 |
| Policy instance | 2 |
| Insurance contract or identification number | 50001464-01 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $1,117 | | Total amount of fees paid to insurance company | USD $4,040 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4040 | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $1,117 | | Insurance broker name | J S CLARK AGENCY INC |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $17,882 | | Total amount of fees paid to insurance company | USD $5,803 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $174,810 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,882 | | Amount paid for insurance broker fees | 5803 | | Insurance broker organization code? | 3 | | Insurance broker name | J S CLARK AGENCY INC |
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| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | CID 415141 |
| Policy instance | 3 |
| Insurance contract or identification number | CID 415141 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $28,020 | | Total amount of fees paid to insurance company | USD $1,811 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,073 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1811 | | Insurance broker name | AGENT BENEFITS CORPORATION |
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| EMPLOYEE HEALTH INSURANCE MANAGEMENT (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50001464-01 |
| Policy instance | 2 |
| Insurance contract or identification number | 50001464-01 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $885 | | Total amount of fees paid to insurance company | USD $2,999 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2999 | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $885 | | Insurance broker name | J S CLARK AGENCY INC |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00466605 |
| Policy instance | 1 |
| Insurance contract or identification number | 00466605 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $14,589 | | Total amount of fees paid to insurance company | USD $5,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,589 | | Amount paid for insurance broker fees | 5196 | | Insurance broker organization code? | 3 | | Insurance broker name | J S CLARK AGENCY INC |
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