HAVERLAND CARTER LIFESTYLE GROUP OPERATING, LLC has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022: LA VIDA LLENA CAFETERIA PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-04-01 | 450 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-04-01 | 447 |
| Number of retired or separated participants receiving benefits | 2022-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-04-01 | 0 |
| Total of all active and inactive participants | 2022-04-01 | 447 |
| 2021: LA VIDA LLENA CAFETERIA PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-04-01 | 447 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-04-01 | 450 |
| 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 | 450 |
| 2020: LA VIDA LLENA CAFETERIA PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-04-01 | 537 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-04-01 | 447 |
| Number of retired or separated participants receiving benefits | 2020-04-01 | 0 |
| 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 | 447 |
| 2019: LA VIDA LLENA CAFETERIA PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-04-01 | 413 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-04-01 | 537 |
| Number of retired or separated participants receiving benefits | 2019-04-01 | 0 |
| 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 | 537 |
| 2018: LA VIDA LLENA CAFETERIA PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-04-01 | 471 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-04-01 | 413 |
| 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 | 413 |
| 2017: LA VIDA LLENA CAFETERIA PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-04-01 | 455 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-04-01 | 364 |
| 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 | 364 |
| 2016: LA VIDA LLENA CAFETERIA PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-04-01 | 253 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-04-01 | 300 |
| 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 | 300 |
| 2015: LA VIDA LLENA CAFETERIA PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-04-01 | 233 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-04-01 | 253 |
| Number of retired or separated participants receiving benefits | 2015-04-01 | 0 |
| 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 | 253 |
| 2014: LA VIDA LLENA CAFETERIA PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-04-01 | 230 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-04-01 | 233 |
| Number of retired or separated participants receiving benefits | 2014-04-01 | 0 |
| 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 | 233 |
| 2013: LA VIDA LLENA CAFETERIA PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-04-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-04-01 | 230 |
| Number of retired or separated participants receiving benefits | 2013-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-04-01 | 0 |
| Total of all active and inactive participants | 2013-04-01 | 230 |
| 2022: LA VIDA LLENA CAFETERIA PLAN 2022 form 5500 responses |
|---|
| 2022-04-01 | Type of plan entity | Single employer plan |
| 2022-04-01 | Submission has been amended | No |
| 2022-04-01 | This submission is the final filing | No |
| 2022-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-04-01 | Plan is a collectively bargained plan | No |
| 2022-04-01 | Plan funding arrangement – Insurance | Yes |
| 2022-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: LA VIDA LLENA CAFETERIA PLAN 2021 form 5500 responses |
|---|
| 2021-04-01 | Type of plan entity | Single employer plan |
| 2021-04-01 | Submission has been amended | No |
| 2021-04-01 | This submission is the final filing | No |
| 2021-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-04-01 | Plan is a collectively bargained plan | No |
| 2021-04-01 | Plan funding arrangement – Insurance | Yes |
| 2021-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: LA VIDA LLENA CAFETERIA PLAN 2020 form 5500 responses |
|---|
| 2020-04-01 | Type of plan entity | Single employer plan |
| 2020-04-01 | Submission has been amended | No |
| 2020-04-01 | This submission is the final filing | No |
| 2020-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-04-01 | Plan is a collectively bargained plan | No |
| 2020-04-01 | Plan funding arrangement – Insurance | Yes |
| 2020-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: LA VIDA LLENA CAFETERIA PLAN 2019 form 5500 responses |
|---|
| 2019-04-01 | Type of plan entity | Single employer plan |
| 2019-04-01 | Submission has been amended | No |
| 2019-04-01 | This submission is the final filing | No |
| 2019-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-04-01 | Plan is a collectively bargained plan | No |
| 2019-04-01 | Plan funding arrangement – Insurance | Yes |
| 2019-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: LA VIDA LLENA CAFETERIA PLAN 2018 form 5500 responses |
|---|
| 2018-04-01 | Type of plan entity | Single employer plan |
| 2018-04-01 | Submission has been amended | No |
| 2018-04-01 | This submission is the final filing | No |
| 2018-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-04-01 | Plan is a collectively bargained plan | No |
| 2018-04-01 | Plan funding arrangement – Insurance | Yes |
| 2018-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: LA VIDA LLENA CAFETERIA PLAN 2017 form 5500 responses |
|---|
| 2017-04-01 | Type of plan entity | Single employer plan |
| 2017-04-01 | Submission has been amended | No |
| 2017-04-01 | This submission is the final filing | No |
| 2017-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-04-01 | Plan is a collectively bargained plan | No |
| 2017-04-01 | Plan funding arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: LA VIDA LLENA CAFETERIA PLAN 2016 form 5500 responses |
|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Submission has been amended | No |
| 2016-04-01 | This submission is the final filing | No |
| 2016-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-04-01 | Plan is a collectively bargained plan | No |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: LA VIDA LLENA CAFETERIA PLAN 2015 form 5500 responses |
|---|
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Submission has been amended | No |
| 2015-04-01 | This submission is the final filing | No |
| 2015-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-04-01 | Plan is a collectively bargained plan | No |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: LA VIDA LLENA CAFETERIA PLAN 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Submission has been amended | No |
| 2014-04-01 | This submission is the final filing | No |
| 2014-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-04-01 | Plan is a collectively bargained plan | No |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: LA VIDA LLENA CAFETERIA PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Submission has been amended | No |
| 2013-04-01 | This submission is the final filing | No |
| 2013-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-04-01 | Plan is a collectively bargained plan | No |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 30039536 |
| Policy instance | 2 |
| Insurance contract or identification number | 30039536 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $1,874 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,874 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 002895 |
| Policy instance | 1 |
| Insurance contract or identification number | 002895 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $75,852 | | Total amount of fees paid to insurance company | USD $14,863 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $687,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $75,852 | | Amount paid for insurance broker fees | 14863 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF NEW MEXICO (National Association of Insurance Commissioners NAIC id number: 47287 ) |
| Policy contract number | 0008563 |
| Policy instance | 3 |
| Insurance contract or identification number | 0008563 | | Number of Individuals Covered | 451 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $6,464 | | Total amount of fees paid to insurance company | USD $0 | | Dental 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 $6,464 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUGOBJKV |
| Policy instance | 4 |
| Insurance contract or identification number | GUGOBJKV | | Number of Individuals Covered | 42 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $958 | | Total amount of fees paid to insurance company | USD $667 | | Other welfare benefits provided | SHORT TERM DISABILITY INSURED | | Welfare Benefit Premiums Paid to Carrier | USD $9,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $958 | | Amount paid for insurance broker fees | 667 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPROBJKV |
| Policy instance | 5 |
| Insurance contract or identification number | GUPROBJKV | | Number of Individuals Covered | 42 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $1,300 | | Total amount of fees paid to insurance company | USD $1,787 | | Other welfare benefits provided | LONG TERM DISABILITY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $26,007 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,300 | | Amount paid for insurance broker fees | 1787 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOBJKV |
| Policy instance | 6 |
| Insurance contract or identification number | GLUGOBJKV | | Number of Individuals Covered | 447 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $1,006 | | Total amount of fees paid to insurance company | USD $703 | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,063 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,006 | | Amount paid for insurance broker fees | 703 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOBJKV |
| Policy instance | 7 |
| Insurance contract or identification number | GVTLOBJKV | | Number of Individuals Covered | 137 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $9,020 | | Total amount of fees paid to insurance company | USD $4,129 | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $60,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,020 | | Amount paid for insurance broker fees | 4129 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUCOBJKV |
| Policy instance | 8 |
| Insurance contract or identification number | GUCOBJKV | | Number of Individuals Covered | 65 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $4,929 | | Total amount of fees paid to insurance company | USD $2,247 | | Other welfare benefits provided | SHORT TERM DISABILITY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $32,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,929 | | Amount paid for insurance broker fees | 2247 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOBJKV |
| Policy instance | 9 |
| Insurance contract or identification number | GLTDOBJKV | | Number of Individuals Covered | 42 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $2,839 | | Total amount of fees paid to insurance company | USD $1,448 | | Other welfare benefits provided | LONG TERM DISABILITY INSURED | | Welfare Benefit Premiums Paid to Carrier | USD $20,885 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,839 | | Amount paid for insurance broker fees | 1448 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOBJKV |
| Policy instance | 3 |
| Insurance contract or identification number | GLTDOBJKV | | Number of Individuals Covered | 38 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $3,067 | | Total amount of fees paid to insurance company | USD $1,575 | | Other welfare benefits provided | LONG TERM DISABILITY INSURED | | Welfare Benefit Premiums Paid to Carrier | USD $23,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,067 | | Amount paid for insurance broker fees | 1575 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOBJKV |
| Policy instance | 2 |
| Insurance contract or identification number | GVTLOBJKV | | Number of Individuals Covered | 165 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-30 | | Total amount of commissions paid to insurance broker | USD $8,496 | | Total amount of fees paid to insurance company | USD $3,692 | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $56,637 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,496 | | Amount paid for insurance broker fees | 3692 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOBJKV |
| Policy instance | 1 |
| Insurance contract or identification number | GLUGOBJKV | | Number of Individuals Covered | 352 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $1,024 | | Total amount of fees paid to insurance company | USD $640 | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,024 | | Amount paid for insurance broker fees | 640 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF NEW MEXICO (National Association of Insurance Commissioners NAIC id number: 47287 ) |
| Policy contract number | 0008563 |
| Policy instance | 8 |
| Insurance contract or identification number | 0008563 | | Number of Individuals Covered | 450 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $6,003 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,003 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 002895 |
| Policy instance | 4 |
| Insurance contract or identification number | 002895 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $76,318 | | Total amount of fees paid to insurance company | USD $19,655 | | 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 $76,318 | | Amount paid for insurance broker fees | 19655 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 30039536 |
| Policy instance | 5 |
| Insurance contract or identification number | 30039536 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $1,457 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,443 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,457 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPROBJKV |
| Policy instance | 6 |
| Insurance contract or identification number | GUPROBJKV | | Number of Individuals Covered | 50 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $1,218 | | Total amount of fees paid to insurance company | USD $1,711 | | Other welfare benefits provided | LONG TERM DISABILITY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $24,359 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,218 | | Amount paid for insurance broker fees | 1711 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUGOBJKV |
| Policy instance | 7 |
| Insurance contract or identification number | GUGOBJKV | | Number of Individuals Covered | 38 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $1,055 | | Total amount of fees paid to insurance company | USD $721 | | Other welfare benefits provided | SHORT TERM DISABILITY INSURED | | Welfare Benefit Premiums Paid to Carrier | USD $10,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,055 | | Amount paid for insurance broker fees | 721 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUCOBJKV |
| Policy instance | 9 |
| Insurance contract or identification number | GUCOBJKV | | Number of Individuals Covered | 70 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $4,369 | | Total amount of fees paid to insurance company | USD $1,994 | | Other welfare benefits provided | SHORT TERM DISABILITY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $29,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,369 | | Amount paid for insurance broker fees | 1994 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUCOBJKV |
| Policy instance | 8 |
| Insurance contract or identification number | GUCOBJKV | | Number of Individuals Covered | 63 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $4,168 | | Total amount of fees paid to insurance company | USD $1,796 | | Other welfare benefits provided | SHORT TERM DISABILITY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $27,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $731 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOBJKV |
| Policy instance | 7 |
| Insurance contract or identification number | GVTLOBJKV | | Number of Individuals Covered | 161 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-30 | | Total amount of commissions paid to insurance broker | USD $7,782 | | Total amount of fees paid to insurance company | USD $3,367 | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $51,884 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,403 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOBJKV |
| Policy instance | 6 |
| Insurance contract or identification number | GLUGOBJKV | | Number of Individuals Covered | 349 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $1,014 | | Total amount of fees paid to insurance company | USD $772 | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,136 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $249 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPROBJKV |
| Policy instance | 5 |
| Insurance contract or identification number | GUPROBJKV | | Number of Individuals Covered | 53 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $1,309 | | Total amount of fees paid to insurance company | USD $1,707 | | Other welfare benefits provided | LONG TERM DISABILITY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $26,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $231 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | ` | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUGOBJKV |
| Policy instance | 4 |
| Insurance contract or identification number | GUGOBJKV | | Number of Individuals Covered | 40 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $933 | | Total amount of fees paid to insurance company | USD $668 | | Other welfare benefits provided | SHORT TERM DISABILITY INSURED | | Welfare Benefit Premiums Paid to Carrier | USD $9,334 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $193 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 6 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| DELTA DENTAL OF NEW MEXICO (National Association of Insurance Commissioners NAIC id number: 47287 ) |
| Policy contract number | 0008563 |
| Policy instance | 3 |
| Insurance contract or identification number | 0008563 | | Number of Individuals Covered | 433 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $6,148 | | Total amount of fees paid to insurance company | USD $0 | | Dental 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 $6,148 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 30039536 |
| Policy instance | 2 |
| Insurance contract or identification number | 30039536 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $1,650 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,323 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,012 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 002895 |
| Policy instance | 1 |
| Insurance contract or identification number | 002895 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $88,249 | | Total amount of fees paid to insurance company | USD $2,464 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $605,492 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $88,249 | | Amount paid for insurance broker fees | 2464 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOBJKV |
| Policy instance | 9 |
| Insurance contract or identification number | GLTDOBJKV | | Number of Individuals Covered | 40 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $2,716 | | Total amount of fees paid to insurance company | USD $1,400 | | Other welfare benefits provided | LONG TERM DISABILITY INSURED | | Welfare Benefit Premiums Paid to Carrier | USD $19,657 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $601 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOBJKV |
| Policy instance | 6 |
| Insurance contract or identification number | GLUGOBJKV | | Number of Individuals Covered | 537 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $1,402 | | Total amount of fees paid to insurance company | USD $767 | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $14,020 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,402 | | Amount paid for insurance broker fees | 767 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUGOBJKV |
| Policy instance | 4 |
| Insurance contract or identification number | GUGOBJKV | | Number of Individuals Covered | 47 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $1,089 | | Total amount of fees paid to insurance company | USD $548 | | Other welfare benefits provided | SHORT TERM DISABILITY INSURED | | Welfare Benefit Premiums Paid to Carrier | USD $10,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,089 | | Amount paid for insurance broker fees | 548 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF NEW MEXICO (National Association of Insurance Commissioners NAIC id number: 47287 ) |
| Policy contract number | 0010284 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010284 | | Number of Individuals Covered | 475 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $12,295 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,295 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 30039536 |
| Policy instance | 2 |
| Insurance contract or identification number | 30039536 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $1,538 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,297 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,538 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 002895 |
| Policy instance | 1 |
| Insurance contract or identification number | 002895 | | Number of Individuals Covered | 325 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $89,670 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $552,071 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $89,670 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOBJKV |
| Policy instance | 7 |
| Insurance contract or identification number | GVTLOBJKV | | Number of Individuals Covered | 188 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-30 | | Total amount of commissions paid to insurance broker | USD $7,696 | | Total amount of fees paid to insurance company | USD $2,590 | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $51,307 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,696 | | Amount paid for insurance broker fees | 2590 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUCOBJKV |
| Policy instance | 8 |
| Insurance contract or identification number | GUCOBJKV | | Number of Individuals Covered | 69 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $4,166 | | Total amount of fees paid to insurance company | USD $1,668 | | Other welfare benefits provided | SHORT TERM DISABILITY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $27,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,166 | | Amount paid for insurance broker fees | 1668 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOBJKV |
| Policy instance | 9 |
| Insurance contract or identification number | GLTDOBJKV | | Number of Individuals Covered | 47 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $3,035 | | Total amount of fees paid to insurance company | USD $1,173 | | Other welfare benefits provided | LONG TERM DISABILITY INSURED | | Welfare Benefit Premiums Paid to Carrier | USD $22,848 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,035 | | Amount paid for insurance broker fees | 1173 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPROBJKV |
| Policy instance | 5 |
| Insurance contract or identification number | GUPROBJKV | | Number of Individuals Covered | 58 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $1,306 | | Total amount of fees paid to insurance company | USD $1,622 | | Other welfare benefits provided | LONG TERM DISABILITY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $26,118 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,306 | | Amount paid for insurance broker fees | 1622 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 002895 |
| Policy instance | 5 |
| Insurance contract or identification number | 002895 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $81,560 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $481,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $81,560 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 30039536 |
| Policy instance | 2 |
| Insurance contract or identification number | 30039536 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $1,420 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,780 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,420 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF NEW MEXICO (National Association of Insurance Commissioners NAIC id number: 47287 ) |
| Policy contract number | 0010284 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010284 | | Number of Individuals Covered | 413 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $6,292 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,292 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 820593 |
| Policy instance | 4 |
| Insurance contract or identification number | 820593 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2018-04-02 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $17 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $147 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 095736 |
| Policy instance | 1 |
| Insurance contract or identification number | 095736 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $3,307 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $24,344 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,003 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 002895 |
| Policy instance | 2 |
| Insurance contract or identification number | 002895 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $84,720 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,817,426 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $84,720 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INSURANCE SERVCE |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 30039536 |
| Policy instance | 3 |
| Insurance contract or identification number | 30039536 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $1,318 | | Total amount of fees paid to insurance company | USD $0 | | Vision 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 $1,318 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INSURANCE SERVICE |
|
| DELTA DENTAL OF NEW MEXICO (National Association of Insurance Commissioners NAIC id number: 47287 ) |
| Policy contract number | 0010284 |
| Policy instance | 4 |
| Insurance contract or identification number | 0010284 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $7,110 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,110 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INSURANCE SERVICE |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | BCM003091 |
| Policy instance | 5 |
| Insurance contract or identification number | BCM003091 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $2,991 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,968 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,991 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS SVCS, INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | BEC003092 |
| Policy instance | 6 |
| Insurance contract or identification number | BEC003092 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 095736 |
| Policy instance | 1 |
| Insurance contract or identification number | 095736 | | Number of Individuals Covered | 260 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $5,484 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $41,485 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,965 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS SVCS |
|
