PARK NATIONAL CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN
401k plan membership statisitcs for PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN
| Measure | Date | Value |
|---|
| 2019: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 1 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 0 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 0 |
| Total participants | 2019-10-01 | 0 |
| 2018: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 2 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 1 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 1 |
| Total participants | 2018-10-01 | 1 |
| 2017: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 5 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 2 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 2 |
| Total participants | 2017-10-01 | 2 |
| 2016: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 7 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 5 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 5 |
| Total participants | 2016-10-01 | 5 |
| 2015: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 8 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 7 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 7 |
| Total participants | 2015-10-01 | 7 |
| 2014: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 10 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 9 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
| Total of all active and inactive participants | 2014-10-01 | 9 |
| Total participants | 2014-10-01 | 9 |
| 2013: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 10 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 9 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-10-01 | 0 |
| Total of all active and inactive participants | 2013-10-01 | 9 |
| Total participants | 2013-10-01 | 9 |
| 2011: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 13 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 12 |
| Number of retired or separated participants receiving benefits | 2011-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-10-01 | 0 |
| Total of all active and inactive participants | 2011-10-01 | 12 |
| Total participants | 2011-10-01 | 12 |
| 2010: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-10-01 | 13 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 12 |
| Number of retired or separated participants receiving benefits | 2010-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-10-01 | 0 |
| Total of all active and inactive participants | 2010-10-01 | 12 |
| Total participants | 2010-10-01 | 12 |
| 2009: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 13 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 13 |
| Number of retired or separated participants receiving benefits | 2009-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-10-01 | 0 |
| Total of all active and inactive participants | 2009-10-01 | 13 |
| Total participants | 2009-10-01 | 13 |
| Measure | Date | Value |
|---|
| 2019 : PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2019 401k financial data |
|---|
| Total income from all sources | 2019-12-31 | $236 |
| Expenses. Total of all expenses incurred | 2019-12-31 | $236 |
| Benefits paid (including direct rollovers) | 2019-12-31 | $41 |
| Total plan assets at end of year | 2019-12-31 | $2,475 |
| Total plan assets at beginning of year | 2019-12-31 | $2,475 |
| Value of fidelity bond covering the plan | 2019-12-31 | $1,000,000 |
| Expenses. Other expenses not covered elsewhere | 2019-12-31 | $145 |
| Net income (gross income less expenses) | 2019-12-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2019-12-31 | $2,475 |
| Net plan assets at beginning of year (total assets less liabilities) | 2019-12-31 | $2,475 |
| Total contributions received or receivable from employer(s) | 2019-12-31 | $236 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2019-12-31 | $50 |
| Total income from all sources | 2019-09-30 | $7,787 |
| Expenses. Total of all expenses incurred | 2019-09-30 | $7,520 |
| Benefits paid (including direct rollovers) | 2019-09-30 | $6,121 |
| Total plan assets at end of year | 2019-09-30 | $2,475 |
| Total plan assets at beginning of year | 2019-09-30 | $2,208 |
| Value of fidelity bond covering the plan | 2019-09-30 | $1,000,000 |
| Expenses. Other expenses not covered elsewhere | 2019-09-30 | $1,019 |
| Net income (gross income less expenses) | 2019-09-30 | $267 |
| Net plan assets at end of year (total assets less liabilities) | 2019-09-30 | $2,475 |
| Net plan assets at beginning of year (total assets less liabilities) | 2019-09-30 | $2,208 |
| Total contributions received or receivable from employer(s) | 2019-09-30 | $7,787 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2019-09-30 | $380 |
| 2017 : PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2017 401k financial data |
|---|
| Total income from all sources | 2017-09-30 | $27,670 |
| Expenses. Total of all expenses incurred | 2017-09-30 | $27,765 |
| Benefits paid (including direct rollovers) | 2017-09-30 | $23,477 |
| Total plan assets at end of year | 2017-09-30 | $2,218 |
| Total plan assets at beginning of year | 2017-09-30 | $2,313 |
| Value of fidelity bond covering the plan | 2017-09-30 | $10,000,000 |
| Expenses. Other expenses not covered elsewhere | 2017-09-30 | $3,232 |
| Net income (gross income less expenses) | 2017-09-30 | $-95 |
| Net plan assets at end of year (total assets less liabilities) | 2017-09-30 | $2,218 |
| Net plan assets at beginning of year (total assets less liabilities) | 2017-09-30 | $2,313 |
| Total contributions received or receivable from employer(s) | 2017-09-30 | $27,670 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2017-09-30 | $1,056 |
| 2016 : PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2016 401k financial data |
|---|
| Total income from all sources | 2016-09-30 | $21,084 |
| Expenses. Total of all expenses incurred | 2016-09-30 | $21,084 |
| Benefits paid (including direct rollovers) | 2016-09-30 | $15,454 |
| Total plan assets at end of year | 2016-09-30 | $2,313 |
| Total plan assets at beginning of year | 2016-09-30 | $2,313 |
| Expenses. Other expenses not covered elsewhere | 2016-09-30 | $4,128 |
| Net income (gross income less expenses) | 2016-09-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2016-09-30 | $2,313 |
| Net plan assets at beginning of year (total assets less liabilities) | 2016-09-30 | $2,313 |
| Total contributions received or receivable from employer(s) | 2016-09-30 | $21,084 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2016-09-30 | $1,502 |
| 2015 : PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2015 401k financial data |
|---|
| Total income from all sources | 2015-09-30 | $27,027 |
| Expenses. Total of all expenses incurred | 2015-09-30 | $26,507 |
| Benefits paid (including direct rollovers) | 2015-09-30 | $20,690 |
| Total plan assets at end of year | 2015-09-30 | $2,313 |
| Total plan assets at beginning of year | 2015-09-30 | $1,793 |
| Value of fidelity bond covering the plan | 2015-09-30 | $20,000,000 |
| Expenses. Other expenses not covered elsewhere | 2015-09-30 | $4,185 |
| Net income (gross income less expenses) | 2015-09-30 | $520 |
| Net plan assets at end of year (total assets less liabilities) | 2015-09-30 | $2,313 |
| Net plan assets at beginning of year (total assets less liabilities) | 2015-09-30 | $1,793 |
| Total contributions received or receivable from employer(s) | 2015-09-30 | $27,027 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2015-09-30 | $1,632 |
| 2014 : PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2014 401k financial data |
|---|
| Total income from all sources | 2014-09-30 | $23,096 |
| Expenses. Total of all expenses incurred | 2014-09-30 | $28,112 |
| Benefits paid (including direct rollovers) | 2014-09-30 | $22,934 |
| Total plan assets at end of year | 2014-09-30 | $1,793 |
| Total plan assets at beginning of year | 2014-09-30 | $6,809 |
| Value of fidelity bond covering the plan | 2014-09-30 | $20,000,000 |
| Expenses. Other expenses not covered elsewhere | 2014-09-30 | $3,402 |
| Net income (gross income less expenses) | 2014-09-30 | $-5,016 |
| Net plan assets at end of year (total assets less liabilities) | 2014-09-30 | $1,793 |
| Net plan assets at beginning of year (total assets less liabilities) | 2014-09-30 | $6,809 |
| Total contributions received or receivable from employer(s) | 2014-09-30 | $23,096 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2014-09-30 | $1,776 |
| 2012 : PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2012 401k financial data |
|---|
| Total income from all sources | 2012-09-30 | $58,983 |
| Expenses. Total of all expenses incurred | 2012-09-30 | $64,106 |
| Benefits paid (including direct rollovers) | 2012-09-30 | $57,366 |
| Total plan assets at end of year | 2012-09-30 | $3,065 |
| Total plan assets at beginning of year | 2012-09-30 | $8,188 |
| Value of fidelity bond covering the plan | 2012-09-30 | $20,000,000 |
| Net income (gross income less expenses) | 2012-09-30 | $-5,123 |
| Net plan assets at end of year (total assets less liabilities) | 2012-09-30 | $3,065 |
| Net plan assets at beginning of year (total assets less liabilities) | 2012-09-30 | $8,188 |
| Total contributions received or receivable from employer(s) | 2012-09-30 | $58,983 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2012-09-30 | $6,740 |
| 2011 : PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2011 401k financial data |
|---|
| Total income from all sources | 2011-09-30 | $30,153 |
| Expenses. Total of all expenses incurred | 2011-09-30 | $29,793 |
| Benefits paid (including direct rollovers) | 2011-09-30 | $23,110 |
| Total plan assets at end of year | 2011-09-30 | $8,188 |
| Total plan assets at beginning of year | 2011-09-30 | $7,828 |
| Value of fidelity bond covering the plan | 2011-09-30 | $20,000,000 |
| Expenses. Other expenses not covered elsewhere | 2011-09-30 | $6,683 |
| Net income (gross income less expenses) | 2011-09-30 | $360 |
| Net plan assets at end of year (total assets less liabilities) | 2011-09-30 | $8,188 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-09-30 | $7,828 |
| Total contributions received or receivable from employer(s) | 2011-09-30 | $30,153 |
| 2019: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Submission has been amended | No |
| 2019-10-01 | This submission is the final filing | Yes |
| 2019-10-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2019-10-01 | Plan is a collectively bargained plan | No |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Submission has been amended | No |
| 2018-10-01 | This submission is the final filing | No |
| 2018-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-10-01 | Plan is a collectively bargained plan | No |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Submission has been amended | No |
| 2017-10-01 | This submission is the final filing | No |
| 2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-10-01 | Plan is a collectively bargained plan | No |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Submission has been amended | No |
| 2016-10-01 | This submission is the final filing | No |
| 2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-10-01 | Plan is a collectively bargained plan | No |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Submission has been amended | No |
| 2013-10-01 | This submission is the final filing | No |
| 2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-10-01 | Plan is a collectively bargained plan | No |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Submission has been amended | No |
| 2011-10-01 | This submission is the final filing | No |
| 2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-10-01 | Plan is a collectively bargained plan | No |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2010 form 5500 responses |
|---|
| 2010-10-01 | Type of plan entity | Single employer plan |
| 2010-10-01 | First time form 5500 has been submitted | Yes |
| 2010-10-01 | Submission has been amended | No |
| 2010-10-01 | This submission is the final filing | No |
| 2010-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-10-01 | Plan is a collectively bargained plan | No |
| 2010-10-01 | Plan funding arrangement – Insurance | Yes |
| 2010-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: PARK NATIONAL CORPORATION/FIRST KNOX NATIONAL BANK MEDICARE SUPPLEMENT PLAN 2009 form 5500 responses |
|---|
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | Submission has been amended | No |
| 2009-10-01 | This submission is the final filing | No |
| 2009-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-10-01 | Plan is a collectively bargained plan | No |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 10040 |
| Policy instance | 1 |
| Insurance contract or identification number | 10040 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $95 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5 | | Insurance broker organization code? | 5 |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 10040 |
| Policy instance | 1 |
| Insurance contract or identification number | 10040 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $72 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72 | | Insurance broker organization code? | 5 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 10040 |
| Policy instance | 1 |
| Insurance contract or identification number | 10040 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $87 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $724 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 10040 |
| Policy instance | 1 |
| Insurance contract or identification number | 10040 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $290 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $290 | | Insurance broker organization code? | 5 | | Insurance broker name | MEDICAL BENEFITS ADMINISTRATORS |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 10040 |
| Policy instance | 1 |
| Insurance contract or identification number | 10040 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $288 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,402 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $288 | | Insurance broker organization code? | 5 | | Insurance broker name | MEDICAL BENEFITS ADMINISTRATORS |
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| HCC LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | 10040 |
| Policy instance | 1 |
| Insurance contract or identification number | 10040 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $19 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,586 | | Commission paid to Insurance Broker | USD $19 | | Insurance broker organization code? | 5 | | Insurance broker name | MEDICAL BENEFITS ADMINISTRATORS |
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| HCC LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | 10040 |
| Policy instance | 1 |
| Insurance contract or identification number | 10040 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $201 | | Welfare Benefit Premiums Paid to Carrier | USD $1,476 |
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| HCC LIFE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | 10040 |
| Policy instance | 1 |
| Insurance contract or identification number | 10040 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $165 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,372 |
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