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HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameHAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN
Plan identification number 501

HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

HAPPY MOUNTAINS, LLC has sponsored the creation of one or more 401k plans.

Company Name:HAPPY MOUNTAINS, LLC
Employer identification number (EIN):300800383
NAIC Classification:621493
NAIC Description:Freestanding Ambulatory Surgical and Emergency Centers

Additional information about HAPPY MOUNTAINS, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 5426908

More information about HAPPY MOUNTAINS, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-05-01
5012020-05-01
5012019-05-01MAURI QUINN2020-11-27
5012018-05-01MAURI QUINN2019-11-07
5012017-05-01
5012016-05-01

Plan Statistics for HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN

401k plan membership statisitcs for HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN

Measure Date Value
2021: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-05-01479
Total number of active participants reported on line 7a of the Form 55002021-05-01446
Number of retired or separated participants receiving benefits2021-05-011
Number of other retired or separated participants entitled to future benefits2021-05-0131
Total of all active and inactive participants2021-05-01478
2020: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-01233
Total number of active participants reported on line 7a of the Form 55002020-05-01479
Number of retired or separated participants receiving benefits2020-05-010
Number of other retired or separated participants entitled to future benefits2020-05-0183
Total of all active and inactive participants2020-05-01562
2019: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01179
Total number of active participants reported on line 7a of the Form 55002019-05-01228
Number of retired or separated participants receiving benefits2019-05-015
Number of other retired or separated participants entitled to future benefits2019-05-010
Total of all active and inactive participants2019-05-01233
Number of employers contributing to the scheme2019-05-010
2018: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-05-01153
Total number of active participants reported on line 7a of the Form 55002018-05-01177
Number of retired or separated participants receiving benefits2018-05-012
Number of other retired or separated participants entitled to future benefits2018-05-010
Total of all active and inactive participants2018-05-01179
Number of employers contributing to the scheme2018-05-010
2017: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-01144
Total number of active participants reported on line 7a of the Form 55002017-05-01149
Number of retired or separated participants receiving benefits2017-05-014
Number of other retired or separated participants entitled to future benefits2017-05-010
Total of all active and inactive participants2017-05-01153
2016: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01107
Total number of active participants reported on line 7a of the Form 55002016-05-01144
Number of retired or separated participants receiving benefits2016-05-010
Number of other retired or separated participants entitled to future benefits2016-05-010
Total of all active and inactive participants2016-05-01144

Form 5500 Responses for HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN

2021: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-05-01Type of plan entitySingle employer plan
2021-05-01Submission has been amendedNo
2021-05-01This submission is the final filingNo
2021-05-01This return/report is a short plan year return/report (less than 12 months)No
2021-05-01Plan is a collectively bargained planNo
2021-05-01Plan funding arrangement – InsuranceYes
2021-05-01Plan funding arrangement – General assets of the sponsorYes
2021-05-01Plan benefit arrangement – InsuranceYes
2021-05-01Plan benefit arrangement – General assets of the sponsorYes
2020: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Submission has been amendedNo
2020-05-01This submission is the final filingNo
2020-05-01This return/report is a short plan year return/report (less than 12 months)No
2020-05-01Plan is a collectively bargained planNo
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan funding arrangement – General assets of the sponsorYes
2020-05-01Plan benefit arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – General assets of the sponsorYes
2019: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01Plan funding arrangement – InsuranceYes
2019-05-01Plan funding arrangement – General assets of the sponsorYes
2019-05-01Plan benefit arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – General assets of the sponsorYes
2018: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-05-01Type of plan entitySingle employer plan
2018-05-01Plan funding arrangement – InsuranceYes
2018-05-01Plan funding arrangement – General assets of the sponsorYes
2018-05-01Plan benefit arrangement – InsuranceYes
2018-05-01Plan benefit arrangement – General assets of the sponsorYes
2017: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Plan funding arrangement – InsuranceYes
2017-05-01Plan funding arrangement – General assets of the sponsorYes
2017-05-01Plan benefit arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – General assets of the sponsorYes
2016: HAPPY MOUNTAINS LLC DBA PHYSICIANONE URGENT CARE HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01First time form 5500 has been submittedYes
2016-05-01Submission has been amendedNo
2016-05-01This submission is the final filingNo
2016-05-01This return/report is a short plan year return/report (less than 12 months)No
2016-05-01Plan is a collectively bargained planNo
2016-05-01Plan funding arrangement – InsuranceYes
2016-05-01Plan funding arrangement – General assets of the sponsorYes
2016-05-01Plan benefit arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL165537
Policy instance 2
Insurance contract or identification numberGL165537
Number of Individuals Covered395
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $12,498
Total amount of fees paid to insurance companyUSD $0
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 providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $136,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,498
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number773078
Policy instance 1
Insurance contract or identification number773078
Number of Individuals Covered291
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $13,233
Total amount of fees paid to insurance companyUSD $4,176
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,416,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,233
Amount paid for insurance broker fees4176
Additional information about fees paid to insurance broker2022 SIGNATURE MEDICAL/VISION RETENTION INCENTIVE RISK
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number*10252073
Policy instance 3
Insurance contract or identification number*10252073
Number of Individuals Covered446
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $16,016
Total amount of fees paid to insurance companyUSD $9,152
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, VOLUNTARY LIFE, VOLUNTARY AD&D, EMPLOYEE ASSISTANCE PROGRAM
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 $160,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,016
Insurance broker organization code?3
Amount paid for insurance broker fees9152
Additional information about fees paid to insurance brokerOVERRIDES
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10111781001*
Policy instance 1
Insurance contract or identification number10111781001*
Number of Individuals Covered269
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $2,413
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 $18,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,233
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number773078
Policy instance 2
Insurance contract or identification number773078
Number of Individuals Covered353
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $12,536
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 BenefitYes
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?No
Welfare Benefit Premiums Paid to CarrierUSD $2,696,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,536
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10252073
Policy instance 1
Insurance contract or identification number10252073
Number of Individuals Covered446
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $16,016
Total amount of fees paid to insurance companyUSD $9,152
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $160,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,016
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerOVERRIDES
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10111781001
Policy instance 2
Insurance contract or identification number10111781001
Number of Individuals Covered269
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $2,413
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,233
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number773078
Policy instance 3
Insurance contract or identification number773078
Number of Individuals Covered353
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $12,536
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,696,462
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,536
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number*10252073
Policy instance 3
Insurance contract or identification number*10252073
Number of Individuals Covered479
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $12,367
Total amount of fees paid to insurance companyUSD $2,031
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, VOLUNTARY LIFE, VOLUNTARY 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 $123,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,103
Insurance broker organization code?3
Amount paid for insurance broker fees1358
Additional information about fees paid to insurance brokerOVERRIDES
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10111781001
Policy instance 1
Insurance contract or identification number10111781001
Number of Individuals Covered308
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $1,451
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 $15,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,451
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number773078
Policy instance 2
Insurance contract or identification number773078
Number of Individuals Covered405
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $15,508
Total amount of fees paid to insurance companyUSD $10,065
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 BenefitYes
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
Other welfare benefits providedTELEMEDICINE
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 $1,938,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,460
Amount paid for insurance broker fees10065
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number773078
Policy instance 2
Insurance contract or identification number773078
Number of Individuals Covered230
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $56,995
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,514,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees29443
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION DIRECT COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10111781001
Policy instance 1
Insurance contract or identification number10111781001
Number of Individuals Covered184
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $1,530
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,530
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10252073
Policy instance 3
Insurance contract or identification number10252073
Number of Individuals Covered228
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $7,130
Total amount of fees paid to insurance companyUSD $0
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 providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $71,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,130
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract numberMP0000729208
Policy instance 4
Insurance contract or identification numberMP0000729208
Number of Individuals Covered177
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $4,642
Total amount of fees paid to insurance companyUSD $0
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 providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $46,405
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,642
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number773078
Policy instance 3
Insurance contract or identification number773078
Number of Individuals Covered174
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $4,100
Total amount of fees paid to insurance companyUSD $46,300
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,178,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,100
Amount paid for insurance broker fees46300
Additional information about fees paid to insurance brokerINDIRECT AND DIRECT COMPENSATION
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number9066407
Policy instance 2
Insurance contract or identification number9066407
Number of Individuals Covered108
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $3,382
Total amount of fees paid to insurance companyUSD $5,682
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees5682
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10111781001
Policy instance 1
Insurance contract or identification number10111781001
Number of Individuals Covered167
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $432
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $432
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract numberMP0000729208
Policy instance 5
Insurance contract or identification numberMP0000729208
Number of Individuals Covered149
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $6,888
Total amount of fees paid to insurance companyUSD $0
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 providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $68,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,888
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number9066407
Policy instance 4
Insurance contract or identification number9066407
Number of Individuals Covered0
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $39
Total amount of fees paid to insurance companyUSD $4,169
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $14,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees4169
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number773078
Policy instance 3
Insurance contract or identification number773078
Number of Individuals Covered137
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $40,581
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $952,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees40581
Additional information about fees paid to insurance broker2016-2017 PPP INCENTIVE INDIRECT COMPENSATION DIRECT COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number9066407
Policy instance 2
Insurance contract or identification number9066407
Number of Individuals Covered98
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $5,926
Total amount of fees paid to insurance companyUSD $3,933
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $64,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,926
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
Insurance broker nameCBIA SERVICE CORP.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10111781001
Policy instance 1
Insurance contract or identification number10111781001
Number of Individuals Covered121
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $755
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $755
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.

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