CAROLINA PREMIUM BEVERAGE, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN
401k plan membership statisitcs for CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN
| 2022: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2022 form 5500 responses |
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| 2022-05-01 | Type of plan entity | Single employer plan |
| 2022-05-01 | Submission has been amended | No |
| 2022-05-01 | This submission is the final filing | No |
| 2022-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-05-01 | Plan is a collectively bargained plan | No |
| 2022-05-01 | Plan funding arrangement – Insurance | Yes |
| 2022-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2021 form 5500 responses |
|---|
| 2021-05-01 | Type of plan entity | Single employer plan |
| 2021-05-01 | Submission has been amended | No |
| 2021-05-01 | This submission is the final filing | No |
| 2021-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-05-01 | Plan is a collectively bargained plan | No |
| 2021-05-01 | Plan funding arrangement – Insurance | Yes |
| 2021-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2020 form 5500 responses |
|---|
| 2020-05-01 | Type of plan entity | Single employer plan |
| 2020-05-01 | Submission has been amended | No |
| 2020-05-01 | This submission is the final filing | No |
| 2020-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-05-01 | Plan is a collectively bargained plan | No |
| 2020-05-01 | Plan funding arrangement – Insurance | Yes |
| 2020-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2019 form 5500 responses |
|---|
| 2019-05-01 | Type of plan entity | Single employer plan |
| 2019-05-01 | Submission has been amended | No |
| 2019-05-01 | This submission is the final filing | No |
| 2019-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-05-01 | Plan is a collectively bargained plan | No |
| 2019-05-01 | Plan funding arrangement – Insurance | Yes |
| 2019-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2018 form 5500 responses |
|---|
| 2018-05-01 | Type of plan entity | Single employer plan |
| 2018-05-01 | Submission has been amended | No |
| 2018-05-01 | This submission is the final filing | No |
| 2018-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-05-01 | Plan is a collectively bargained plan | No |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2017 form 5500 responses |
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| 2017-05-01 | Type of plan entity | Single employer plan |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2016 form 5500 responses |
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| 2016-05-01 | Type of plan entity | Single employer plan |
| 2016-05-01 | Submission has been amended | No |
| 2016-05-01 | This submission is the final filing | No |
| 2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-05-01 | Plan is a collectively bargained plan | No |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2015 form 5500 responses |
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| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2014 form 5500 responses |
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| 2014-05-01 | Type of plan entity | Single employer plan |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2013 form 5500 responses |
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| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2012 form 5500 responses |
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| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: CAROLINA PREMIUM BEVERAGE, LLC EMPLOYEE MAJOR MEDICAL PLAN 2011 form 5500 responses |
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| 2011-05-01 | Type of plan entity | Single employer plan |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 029682 |
| Policy instance | 4 |
| Insurance contract or identification number | 029682 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $1,508 | | 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 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 $18,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,508 | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 001364 |
| Policy instance | 3 |
| Insurance contract or identification number | 001364 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $12,822 | | Total amount of fees paid to insurance company | USD $2,151 | | 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 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 | 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 | VOLUNTARY LIFE | | 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 $136,077 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2151 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $12,822 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 47059 |
| Policy instance | 2 |
| Insurance contract or identification number | 47059 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $1,491 | | 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 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 | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,790 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,491 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 47059 |
| Policy instance | 1 |
| Insurance contract or identification number | 47059 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $1,953 | | 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 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 | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT | | 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 $7,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,953 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 141616549001 |
| Policy instance | 5 |
| Insurance contract or identification number | 141616549001 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of fees paid to insurance company | USD $17,009 | | 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 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? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 47059 |
| Policy instance | 1 |
| Insurance contract or identification number | 47059 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $2,241 | | Total amount of fees paid to insurance company | USD $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 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 | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,241 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 14161654-9001 |
| Policy instance | 2 |
| Insurance contract or identification number | 14161654-9001 | | Number of Individuals Covered | 254 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $41,402 | | Total amount of fees paid to insurance company | USD $21,816 | | 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 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,402 | | Amount paid for insurance broker fees | 21816 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 001364 |
| Policy instance | 3 |
| Insurance contract or identification number | 001364 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $19,264 | | Total amount of fees paid to insurance company | USD $5,924 | | 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 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 | 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 | VOLUNTARY INSURANCE | | 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 $81,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3764 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $19,264 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 029682 |
| Policy instance | 4 |
| Insurance contract or identification number | 029682 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $1,986 | | 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 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 $19,862 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,986 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 141616541001 |
| Policy instance | 3 |
| Insurance contract or identification number | 141616541001 | | Number of Individuals Covered | 260 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $44,044 | | 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 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 | | Other welfare benefits provided | WELLNESS | | 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 $1,490,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,044 | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 001364 |
| Policy instance | 2 |
| Insurance contract or identification number | 001364 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $11,976 | | Total amount of fees paid to insurance company | USD $3,919 | | 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 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $63,273 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3919 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $11,976 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 029682 |
| Policy instance | 1 |
| Insurance contract or identification number | 029682 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $2,475 | | 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 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 $24,750 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,475 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 2 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 9202-04-30 | | Total amount of commissions paid to insurance broker | USD $34,915 | | 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 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,915 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 1 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $2,320 | | 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 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 $23,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,320 | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 001364 |
| Policy instance | 3 |
| Insurance contract or identification number | 001364 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $9,075 | | Total amount of fees paid to insurance company | USD $3,794 | | 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 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $48,366 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3795 | | Additional information about fees paid to insurance broker | SERVICE FEE AND BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $9,075 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 001364 |
| Policy instance | 2 |
| Insurance contract or identification number | 001364 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $9,290 | | Total amount of fees paid to insurance company | USD $1,135 | | 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 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $61,689 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Amount paid for insurance broker fees | 1135 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $6,484 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-301263 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-301263 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $963 | | Total amount of fees paid to insurance company | USD $58 | | 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 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 | 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 $7,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 58 | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $834 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 3 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 323 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $47,979 | | Total amount of fees paid to insurance company | USD $567 | | 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 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,979 | | Amount paid for insurance broker fees | 567 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 4 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $1,901 | | 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 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 $19,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,901 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 001364 |
| Policy instance | 4 |
| Insurance contract or identification number | 001364 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $1,230 | | Total amount of fees paid to insurance company | USD $2,910 | | Life 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 $24,465 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 1 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 294 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $29,768 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,015,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 2 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 286 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $1,813 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 1 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 315 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $39,016 | | Total amount of fees paid to insurance company | USD $0 | | 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 $39,016 | | Insurance broker organization code? | 3 | | Insurance broker name | LISA L. HAMLETT |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | G255989 |
| Policy instance | 4 |
| Insurance contract or identification number | G255989 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $2,209 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,398 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,952 | | Insurance broker organization code? | 3 | | Insurance broker name | MOSAIC GROUP SVC, LLC. |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | V255990 |
| Policy instance | 3 |
| Insurance contract or identification number | V255990 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $14,806 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $60,962 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,192 | | Insurance broker organization code? | 3 | | Insurance broker name | MOSAIC GROUP SVC, LLC. |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 2 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $1,778 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,934 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,778 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 1 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $43,022 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 $43,022 | | Insurance broker organization code? | 3 | | Insurance broker name | LISA L. HAMLETT |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141013 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010141013 00 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $1,840 | | Total amount of fees paid to insurance company | USD $70 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $9,200 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,840 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 70 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | WELLS FARGO INS SVCS USA INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141014 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010141014 00 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $3,670 | | Total amount of fees paid to insurance company | USD $138 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,670 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 138 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | WELLS FARGO INS SVCS USA INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141920 00 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010141920 00 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $453 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 13 |
| Policy instance | 5 |
| Insurance contract or identification number | 000400001000 13 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $8,135 | | Total amount of fees paid to insurance company | USD $292 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $40,675 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,135 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 292 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | WELLS FARGO INS SVCS USA INC |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 6 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $1,682 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,682 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 6 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,522 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,384 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,522 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141013 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010141013 00 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,828 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $9,142 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,828 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SVCS USA INC |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 1 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 288 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $38,306 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 $38,306 | | Insurance broker organization code? | 3 | | Insurance broker name | LISA L. HAMLETT |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141014 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010141014 00 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $3,652 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,262 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,652 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SVCS USA INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141920 00 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010141920 00 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 13 |
| Policy instance | 5 |
| Insurance contract or identification number | 000400001000 13 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $7,984 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $39,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,984 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SVCS USA INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 0000400001000 1 |
| Policy instance | 9 |
| Insurance contract or identification number | 0000400001000 1 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $1,304 | | Total amount of fees paid to insurance company | USD $719 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,304 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 719 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141013 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010141013 00 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $1,689 | | Total amount of fees paid to insurance company | USD $189 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,689 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 189 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141014 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010141014 00 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $3,038 | | Total amount of fees paid to insurance company | USD $322 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,188 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,038 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 322 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 1 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $38,397 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 $38,397 | | Insurance broker organization code? | 3 | | Insurance broker name | LISA L. HAMLETT |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141920 00 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010141920 00 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $-10 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 0000400001000 1 |
| Policy instance | 5 |
| Insurance contract or identification number | 0000400001000 1 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $6,744 | | Total amount of fees paid to insurance company | USD $719 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $33,162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,744 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 719 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 6 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $1,515 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,121 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,515 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141013 00 |
| Policy instance | 7 |
| Insurance contract or identification number | 000010141013 00 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $430 | | Total amount of fees paid to insurance company | USD $189 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $430 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 189 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141014 00 |
| Policy instance | 8 |
| Insurance contract or identification number | 000010141014 00 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $848 | | Total amount of fees paid to insurance company | USD $322 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $848 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 322 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 0000400001000 1 |
| Policy instance | 5 |
| Insurance contract or identification number | 0000400001000 1 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $8,128 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $32,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 6 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $1,568 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,845 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141920 00 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010141920 00 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 1 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $43,112 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141014 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010141014 00 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $2,876 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,379 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010141013 00 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010141013 00 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $1,737 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,684 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 868834G |
| Policy instance | 1 |
| Insurance contract or identification number | 868834G | | Number of Individuals Covered | 174 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $8,279 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,188 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 071703 |
| Policy instance | 2 |
| Insurance contract or identification number | 071703 | | Number of Individuals Covered | 313 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $48,861 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 29682 |
| Policy instance | 3 |
| Insurance contract or identification number | 29682 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $1,459 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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