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AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 401k Plan overview

Plan NameAGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN
Plan identification number 501

AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

AGC BACKOFFICE SUPPORT SERVICES, LLC has sponsored the creation of one or more 401k plans.

Company Name:AGC BACKOFFICE SUPPORT SERVICES, LLC
Employer identification number (EIN):272821517
NAIC Classification:561110
NAIC Description:Office Administrative Services

Additional information about AGC BACKOFFICE SUPPORT SERVICES, LLC

Jurisdiction of Incorporation: Oklahoma Secretary Of State
Incorporation Date:
Company Identification Number: 3512275927

More information about AGC BACKOFFICE SUPPORT SERVICES, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-11-01
5012020-11-01
5012020-11-01
5012018-11-01
5012017-11-01JEFF MORTON JEFF MORTON2019-02-26
5012016-11-01JEFF MORTON JEFF MORTON2018-04-24
5012015-11-01JEFF MORTON JEFF MORTON2017-04-05
5012014-11-01JEFF MORTON JEFF MORTON2016-03-31
5012013-11-01KENDRA CLEMENTS
5012012-11-01JEFF MORTON
5012011-11-01JEFF MORTON

Plan Statistics for AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN

401k plan membership statisitcs for AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN

Measure Date Value
2021: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-11-01598
Total number of active participants reported on line 7a of the Form 55002021-11-01529
Number of retired or separated participants receiving benefits2021-11-0111
Number of other retired or separated participants entitled to future benefits2021-11-010
Total of all active and inactive participants2021-11-01540
2020: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-11-01644
Total number of active participants reported on line 7a of the Form 55002020-11-01529
Number of retired or separated participants receiving benefits2020-11-0111
Number of other retired or separated participants entitled to future benefits2020-11-010
Total of all active and inactive participants2020-11-01540
2018: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-11-01282
Total number of active participants reported on line 7a of the Form 55002018-11-01286
Number of retired or separated participants receiving benefits2018-11-012
Number of other retired or separated participants entitled to future benefits2018-11-010
Total of all active and inactive participants2018-11-01288
2017: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-11-01247
Total number of active participants reported on line 7a of the Form 55002017-11-01279
Number of retired or separated participants receiving benefits2017-11-012
Number of other retired or separated participants entitled to future benefits2017-11-010
Total of all active and inactive participants2017-11-01281
2016: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-11-01427
Total number of active participants reported on line 7a of the Form 55002016-11-01443
Number of retired or separated participants receiving benefits2016-11-012
Number of other retired or separated participants entitled to future benefits2016-11-010
Total of all active and inactive participants2016-11-01445
2015: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-11-01344
Total number of active participants reported on line 7a of the Form 55002015-11-01420
Number of retired or separated participants receiving benefits2015-11-011
Number of other retired or separated participants entitled to future benefits2015-11-010
Total of all active and inactive participants2015-11-01421
2014: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-11-01359
Total number of active participants reported on line 7a of the Form 55002014-11-01342
Number of retired or separated participants receiving benefits2014-11-012
Number of other retired or separated participants entitled to future benefits2014-11-010
Total of all active and inactive participants2014-11-01344
2013: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-11-01398
Total number of active participants reported on line 7a of the Form 55002013-11-01263
Number of retired or separated participants receiving benefits2013-11-015
Number of other retired or separated participants entitled to future benefits2013-11-010
Total of all active and inactive participants2013-11-01268
2012: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-11-01448
Total number of active participants reported on line 7a of the Form 55002012-11-01444
Number of retired or separated participants receiving benefits2012-11-014
Number of other retired or separated participants entitled to future benefits2012-11-010
Total of all active and inactive participants2012-11-01448
2011: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-11-01292
Total number of active participants reported on line 7a of the Form 55002011-11-01438
Number of retired or separated participants receiving benefits2011-11-014
Number of other retired or separated participants entitled to future benefits2011-11-010
Total of all active and inactive participants2011-11-01442

Form 5500 Responses for AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN

2021: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2021 form 5500 responses
2021-11-01Type of plan entitySingle employer plan
2021-11-01Submission has been amendedNo
2021-11-01This submission is the final filingNo
2021-11-01This return/report is a short plan year return/report (less than 12 months)No
2021-11-01Plan is a collectively bargained planNo
2021-11-01Plan funding arrangement – General assets of the sponsorYes
2021-11-01Plan benefit arrangement – InsuranceYes
2021-11-01Plan benefit arrangement – General assets of the sponsorYes
2020: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2020 form 5500 responses
2020-11-01Type of plan entitySingle employer plan
2020-11-01Submission has been amendedNo
2020-11-01This submission is the final filingNo
2020-11-01This return/report is a short plan year return/report (less than 12 months)No
2020-11-01Plan is a collectively bargained planNo
2020-11-01Plan funding arrangement – General assets of the sponsorYes
2020-11-01Plan benefit arrangement – InsuranceYes
2020-11-01Plan benefit arrangement – General assets of the sponsorYes
2018: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2018 form 5500 responses
2018-11-01Type of plan entitySingle employer plan
2018-11-01Submission has been amendedNo
2018-11-01This submission is the final filingNo
2018-11-01This return/report is a short plan year return/report (less than 12 months)No
2018-11-01Plan is a collectively bargained planNo
2018-11-01Plan funding arrangement – InsuranceYes
2018-11-01Plan funding arrangement – General assets of the sponsorYes
2018-11-01Plan benefit arrangement – InsuranceYes
2018-11-01Plan benefit arrangement – General assets of the sponsorYes
2017: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2017 form 5500 responses
2017-11-01Type of plan entitySingle employer plan
2017-11-01Submission has been amendedNo
2017-11-01This submission is the final filingNo
2017-11-01This return/report is a short plan year return/report (less than 12 months)No
2017-11-01Plan is a collectively bargained planNo
2017-11-01Plan funding arrangement – InsuranceYes
2017-11-01Plan funding arrangement – General assets of the sponsorYes
2017-11-01Plan benefit arrangement – InsuranceYes
2017-11-01Plan benefit arrangement – General assets of the sponsorYes
2016: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2016 form 5500 responses
2016-11-01Type of plan entitySingle employer plan
2016-11-01Submission has been amendedNo
2016-11-01This submission is the final filingNo
2016-11-01This return/report is a short plan year return/report (less than 12 months)No
2016-11-01Plan is a collectively bargained planNo
2016-11-01Plan funding arrangement – InsuranceYes
2016-11-01Plan funding arrangement – General assets of the sponsorYes
2016-11-01Plan benefit arrangement – InsuranceYes
2016-11-01Plan benefit arrangement – General assets of the sponsorYes
2015: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2015 form 5500 responses
2015-11-01Type of plan entitySingle employer plan
2015-11-01Submission has been amendedNo
2015-11-01This submission is the final filingNo
2015-11-01This return/report is a short plan year return/report (less than 12 months)No
2015-11-01Plan is a collectively bargained planNo
2015-11-01Plan funding arrangement – InsuranceYes
2015-11-01Plan funding arrangement – General assets of the sponsorYes
2015-11-01Plan benefit arrangement – InsuranceYes
2015-11-01Plan benefit arrangement – General assets of the sponsorYes
2014: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2014 form 5500 responses
2014-11-01Type of plan entitySingle employer plan
2014-11-01Submission has been amendedNo
2014-11-01This submission is the final filingNo
2014-11-01This return/report is a short plan year return/report (less than 12 months)No
2014-11-01Plan is a collectively bargained planNo
2014-11-01Plan funding arrangement – InsuranceYes
2014-11-01Plan funding arrangement – General assets of the sponsorYes
2014-11-01Plan benefit arrangement – InsuranceYes
2014-11-01Plan benefit arrangement – General assets of the sponsorYes
2013: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2013 form 5500 responses
2013-11-01Type of plan entitySingle employer plan
2013-11-01Submission has been amendedNo
2013-11-01This submission is the final filingNo
2013-11-01This return/report is a short plan year return/report (less than 12 months)No
2013-11-01Plan is a collectively bargained planNo
2013-11-01Plan funding arrangement – InsuranceYes
2013-11-01Plan funding arrangement – General assets of the sponsorYes
2013-11-01Plan benefit arrangement – InsuranceYes
2013-11-01Plan benefit arrangement – General assets of the sponsorYes
2012: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2012 form 5500 responses
2012-11-01Type of plan entitySingle employer plan
2012-11-01Submission has been amendedNo
2012-11-01This submission is the final filingNo
2012-11-01This return/report is a short plan year return/report (less than 12 months)No
2012-11-01Plan is a collectively bargained planNo
2012-11-01Plan funding arrangement – InsuranceYes
2012-11-01Plan funding arrangement – General assets of the sponsorYes
2012-11-01Plan benefit arrangement – InsuranceYes
2012-11-01Plan benefit arrangement – General assets of the sponsorYes
2011: AGC BACKOFFICE SUPPORT SERVICES, LLC HEALTH BENEFIT PLAN 2011 form 5500 responses
2011-11-01Type of plan entitySingle employer plan
2011-11-01Submission has been amendedNo
2011-11-01This submission is the final filingNo
2011-11-01This return/report is a short plan year return/report (less than 12 months)No
2011-11-01Plan is a collectively bargained planNo
2011-11-01Plan funding arrangement – InsuranceYes
2011-11-01Plan funding arrangement – General assets of the sponsorYes
2011-11-01Plan benefit arrangement – InsuranceYes
2011-11-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number251705
Policy instance 6
Insurance contract or identification number251705
Number of Individuals Covered520
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $107,555
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedMEDICAL
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?Yes
Welfare Benefit Premiums Paid to CarrierUSD $794,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $107,555
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT COMMISSION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK752568
Policy instance 5
Insurance contract or identification numberLK752568
Number of Individuals Covered529
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $24,564
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $159,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,564
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK966094
Policy instance 4
Insurance contract or identification numberLK966094
Number of Individuals Covered529
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $18,948
Total amount of fees paid to insurance companyUSD $12
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $123,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,948
Amount paid for insurance broker fees12
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK970598
Policy instance 3
Insurance contract or identification numberOK970598
Number of Individuals Covered247
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $6,196
Total amount of fees paid to insurance companyUSD $2
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,196
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX969144
Policy instance 2
Insurance contract or identification numberFLX969144
Number of Individuals Covered529
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $26,800
Total amount of fees paid to insurance companyUSD $14
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $178,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,800
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022201
Policy instance 1
Insurance contract or identification number30022201
Number of Individuals Covered307
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $2,084
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $64,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,084
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT COMMISSION
Insurance broker organization code?3
DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )
Policy contract number9990008
Policy instance 7
Insurance contract or identification number9990008
Number of Individuals Covered365
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $795
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,084
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT COMMISSION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022201
Policy instance 1
Insurance contract or identification number30022201
Number of Individuals Covered328
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $2,309
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $75,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,309
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT COMMISSION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX969144
Policy instance 2
Insurance contract or identification numberFLX969144
Number of Individuals Covered529
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $14,403
Total amount of fees paid to insurance companyUSD $960
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $98,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,403
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK970598
Policy instance 3
Insurance contract or identification numberOK970598
Number of Individuals Covered379
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $4,403
Total amount of fees paid to insurance companyUSD $587
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,403
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK966094
Policy instance 4
Insurance contract or identification numberLK966094
Number of Individuals Covered529
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $11,633
Total amount of fees paid to insurance companyUSD $776
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $77,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,633
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK752568
Policy instance 5
Insurance contract or identification numberLK752568
Number of Individuals Covered529
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $14,355
Total amount of fees paid to insurance companyUSD $957
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $95,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,355
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AMNQ
Policy instance 1
Insurance contract or identification numberGVTL0AMNQ
Number of Individuals Covered109
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $12,003
Total amount of fees paid to insurance companyUSD $2,431
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $80,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,003
Insurance broker organization code?3
Amount paid for insurance broker fees2431
Additional information about fees paid to insurance brokerOTHER COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AMNQ
Policy instance 2
Insurance contract or identification numberGLTD0AMNQ
Number of Individuals Covered286
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $8,708
Total amount of fees paid to insurance companyUSD $1,750
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,708
Insurance broker organization code?3
Amount paid for insurance broker fees1750
Additional information about fees paid to insurance brokerOTHER COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0AMNQ
Policy instance 3
Insurance contract or identification numberGUG 0AMNQ
Number of Individuals Covered286
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $13,992
Total amount of fees paid to insurance companyUSD $2,787
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $93,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,992
Insurance broker organization code?3
Amount paid for insurance broker fees2787
Additional information about fees paid to insurance brokerOTHER COMPENSATION
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022201
Policy instance 4
Insurance contract or identification number30022201
Number of Individuals Covered163
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $145
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $145
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AMNQ
Policy instance 5
Insurance contract or identification numberGLUG0AMNQ
Number of Individuals Covered286
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $3,512
Total amount of fees paid to insurance companyUSD $752
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $23,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,512
Insurance broker organization code?3
Amount paid for insurance broker fees752
Additional information about fees paid to insurance brokerOTHER COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AMNQ
Policy instance 5
Insurance contract or identification numberGLUG0AMNQ
Number of Individuals Covered257
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $2,212
Total amount of fees paid to insurance companyUSD $2,138
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $14,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022201
Policy instance 4
Insurance contract or identification number30022201
Number of Individuals Covered181
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $1,290
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0AMNQ
Policy instance 3
Insurance contract or identification numberGUG 0AMNQ
Number of Individuals Covered278
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $8,165
Total amount of fees paid to insurance companyUSD $6,987
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $54,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AMNQ
Policy instance 2
Insurance contract or identification numberGLTD0AMNQ
Number of Individuals Covered279
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $5,159
Total amount of fees paid to insurance companyUSD $4,573
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AMNQ
Policy instance 1
Insurance contract or identification numberGVTL0AMNQ
Number of Individuals Covered112
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $7,326
Total amount of fees paid to insurance companyUSD $4,836
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $48,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AMNQ
Policy instance 2
Insurance contract or identification numberGLTD0AMNQ
Number of Individuals Covered420
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $9,593
Total amount of fees paid to insurance companyUSD $1,575
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $63,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,593
Amount paid for insurance broker fees1575
Additional information about fees paid to insurance brokerTOTAL FEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AMNQ
Policy instance 5
Insurance contract or identification numberGLUG0AMNQ
Number of Individuals Covered420
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $4,822
Total amount of fees paid to insurance companyUSD $843
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $32,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,822
Amount paid for insurance broker fees843
Additional information about fees paid to insurance brokerTOTAL FEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )
Policy contract number30022201
Policy instance 4
Insurance contract or identification number30022201
Number of Individuals Covered250
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $1,946
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $55,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,946
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0AMNQ
Policy instance 3
Insurance contract or identification numberGUG 0AMNQ
Number of Individuals Covered420
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $13,318
Total amount of fees paid to insurance companyUSD $2,213
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $88,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,318
Amount paid for insurance broker fees2213
Additional information about fees paid to insurance brokerTOTAL FEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AMNQ
Policy instance 1
Insurance contract or identification numberGVTL0AMNQ
Number of Individuals Covered155
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $9,567
Total amount of fees paid to insurance companyUSD $1,774
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $63,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,567
Amount paid for insurance broker fees1774
Additional information about fees paid to insurance brokerTOTAL FEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AMNQ
Policy instance 1
Insurance contract or identification numberGVTL0AMNQ
Number of Individuals Covered112
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $7,927
Total amount of fees paid to insurance companyUSD $4,671
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $52,846
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,927
Amount paid for insurance broker fees4671
Additional information about fees paid to insurance brokerSERVICE FEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AMNQ
Policy instance 2
Insurance contract or identification numberGLTD0AMNQ
Number of Individuals Covered342
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $7,173
Total amount of fees paid to insurance companyUSD $4,164
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $47,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,173
Amount paid for insurance broker fees4164
Additional information about fees paid to insurance brokerSERVICE FEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0AMNQ
Policy instance 3
Insurance contract or identification numberGUG 0AMNQ
Number of Individuals Covered338
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $9,718
Total amount of fees paid to insurance companyUSD $4,959
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $64,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,718
Amount paid for insurance broker fees4959
Additional information about fees paid to insurance brokerSERVICE FEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )
Policy contract number30022201
Policy instance 4
Insurance contract or identification number30022201
Number of Individuals Covered197
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $1,732
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $44,101
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,732
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AMNQ
Policy instance 5
Insurance contract or identification numberGLUG0AMNQ
Number of Individuals Covered341
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $3,900
Total amount of fees paid to insurance companyUSD $2,542
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $25,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,900
Amount paid for insurance broker fees2542
Additional information about fees paid to insurance brokerSERVICE FEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number232026
Policy instance 1
Insurance contract or identification number232026
Number of Individuals Covered254
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $22,830
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $367,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,220
Insurance broker organization code?3
Insurance broker nameSTOP LOSS COALITION SERVICES LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )
Policy contract number30022201
Policy instance 2
Insurance contract or identification number30022201
Number of Individuals Covered211
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $1,902
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $52,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,902
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AMNQ
Policy instance 3
Insurance contract or identification numberGLUG0AMNQ
Number of Individuals Covered357
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $5,274
Total amount of fees paid to insurance companyUSD $1,210
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD & D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,274
Amount paid for insurance broker fees1210
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
Insurance broker nameINSERVICES INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AMNQ
Policy instance 4
Insurance contract or identification numberGLTD0AMNQ
Number of Individuals Covered357
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $8,537
Total amount of fees paid to insurance companyUSD $1,554
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $56,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,537
Amount paid for insurance broker fees1554
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AMNQ
Policy instance 5
Insurance contract or identification numberGVTL0AMNQ
Number of Individuals Covered105
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $9,350
Total amount of fees paid to insurance companyUSD $2,064
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOL LIFE AND AD & D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $62,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,350
Amount paid for insurance broker fees2064
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0AMNQ
Policy instance 6
Insurance contract or identification numberGUG0AMNQ
Number of Individuals Covered312
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $9,748
Total amount of fees paid to insurance companyUSD $2,197
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $64,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,748
Amount paid for insurance broker fees2197
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AMNQ
Policy instance 6
Insurance contract or identification numberG000AMNQ
Number of Individuals Covered456
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $9,925
Total amount of fees paid to insurance companyUSD $456
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $66,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,925
Amount paid for insurance broker fees456
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSERVICES INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AMNQ
Policy instance 3
Insurance contract or identification numberG000AMNQ
Number of Individuals Covered418
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $7,429
Total amount of fees paid to insurance companyUSD $333
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,429
Amount paid for insurance broker fees333
Additional information about fees paid to insurance brokerOHTER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSERVICES INC
QBE A&H (National Association of Insurance Commissioners NAIC id number: 39217 )
Policy contract numberLGS00883-12
Policy instance 2
Insurance contract or identification numberLGS00883-12
Number of Individuals Covered333
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $376,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AMNQ
Policy instance 4
Insurance contract or identification numberG000AMNQ
Number of Individuals Covered457
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $5,652
Total amount of fees paid to insurance companyUSD $212
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $37,682
Commission paid to Insurance BrokerUSD $5,652
Amount paid for insurance broker fees212
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSERVICES INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AMNQ
Policy instance 5
Insurance contract or identification numberG000AMNQ
Number of Individuals Covered379
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $10,624
Total amount of fees paid to insurance companyUSD $410
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSHORT TERM DISABILITY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $70,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,624
Amount paid for insurance broker fees410
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSERVICES INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )
Policy contract number30022201
Policy instance 1
Insurance contract or identification number30022201
Number of Individuals Covered250
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $1,908
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $52,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,908
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameINSERVICES, INC.
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17905/80774
Policy instance 1
Insurance contract or identification numberHCL17905/80774
Number of Individuals Covered320
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $78,209
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $443,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )
Policy contract number30022201
Policy instance 3
Insurance contract or identification number30022201
Number of Individuals Covered246
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $1,662
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $41,070
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 number94682
Policy instance 2
Insurance contract or identification number94682
Number of Individuals Covered463
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $17,553
Total amount of fees paid to insurance companyUSD $163
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSHORT TERM DISABILITY, AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $127,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL17905/80774
Policy instance 1
Insurance contract or identification numberHCL17905/80774
Number of Individuals Covered208
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $67,947
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $391,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )
Policy contract number30022201
Policy instance 2
Insurance contract or identification number30022201
Number of Individuals Covered153
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $1,842
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $34,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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