ASAMA COLDWATER MANUFACTURING, INC. has sponsored the creation of one or more 401k plans.
Additional information about ASAMA COLDWATER MANUFACTURING, INC.
Submission information for form 5500 for 401k plan ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 334 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 333 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 336 |
| 2021: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 339 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 332 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 334 |
| 2020: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 353 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 337 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 339 |
| 2019: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 377 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 353 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 353 |
| 2018: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 391 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 376 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 377 |
| 2017: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 387 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 391 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 391 |
| 2016: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 398 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 387 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 387 |
| 2015: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 399 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 398 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 398 |
| 2014: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 368 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 399 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 399 |
| 2013: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 291 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 368 |
| Total of all active and inactive participants | 2013-01-01 | 368 |
| 2012: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 271 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 291 |
| Total of all active and inactive participants | 2012-01-01 | 291 |
| 2011: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 261 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 271 |
| Total of all active and inactive participants | 2011-01-01 | 271 |
| Total participants | 2011-01-01 | 271 |
| 2010: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 287 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 261 |
| Total of all active and inactive participants | 2010-01-01 | 261 |
| Total participants | 2010-01-01 | 261 |
| 2009: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 333 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 287 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 2 |
| Total of all active and inactive participants | 2009-01-01 | 289 |
| Total participants | 2009-01-01 | 289 |
| 2022: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: ASAMA COLDWATER MANUFACTURING, INC. EMPLOYEE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0869J |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0869J | | Number of Individuals Covered | 147 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $2,992 | | Other welfare benefits provided | LIFE & AD&D (VOLUNTARY) | | Welfare Benefit Premiums Paid to Carrier | USD $86,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2992 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 356 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $915 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $27,380 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 915 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 278 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $3,232 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,903 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3232 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 356 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $2,181 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,678 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2181 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 332 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $2,810 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,305 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2810 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 332 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $1,190 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $26,142 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1190 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 250 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $4,206 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,354 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4206 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0869J |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0869J | | Number of Individuals Covered | 129 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $3,841 | | Other welfare benefits provided | LIFE & AD&D (VOLUNTARY) | | Welfare Benefit Premiums Paid to Carrier | USD $85,472 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3841 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 351 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $2,185 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,450 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2185 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0869J |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0869J | | Number of Individuals Covered | 138 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $3,073 | | Other welfare benefits provided | LIFE & AD&D (VOLUNTARY) | | Welfare Benefit Premiums Paid to Carrier | USD $85,345 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3073 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 351 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $953 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $26,443 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 953 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 268 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $3,319 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $93,468 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3319 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 376 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $1,206 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $27,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1206 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 272 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $4,084 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,822 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4084 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0869J |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0869J | | Number of Individuals Covered | 146 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $3,748 | | Other welfare benefits provided | LIFE & AD&D (VOLUNTARY) | | Welfare Benefit Premiums Paid to Carrier | USD $87,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3748 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 357 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $2,703 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,421 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2703 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 482 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of fees paid to insurance company | USD $1,250 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $26,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1250 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 368 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of fees paid to insurance company | USD $2,780 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2780 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 459 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of fees paid to insurance company | USD $4,179 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $90,977 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4179 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 391 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of fees paid to insurance company | USD $1,335 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $27,705 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1335 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 365 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of fees paid to insurance company | USD $2,898 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $61,620 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2898 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 278 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of fees paid to insurance company | USD $4,854 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4854 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 49267 |
| Policy instance | 4 |
| Insurance contract or identification number | 49267 | | Number of Individuals Covered | 398 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $16,597 | | Total amount of fees paid to insurance company | USD $5,357 | | Welfare Benefit Premiums Paid to Carrier | USD $478,992 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,597 | | Amount paid for insurance broker fees | 5357 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | THE HYLANT GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 410 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of fees paid to insurance company | USD $1,576 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $28,113 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1576 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 304 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of fees paid to insurance company | USD $4,523 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $84,565 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4523 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 388 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of fees paid to insurance company | USD $3,401 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $61,039 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3401 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0301911 |
| Policy instance | 6 |
| Insurance contract or identification number | R0301911 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $299 | | Other welfare benefits provided | GROUP CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $2,652 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $221 | | Insurance broker organization code? | 3 | | Insurance broker name | DWIGHT L. PIERCE |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 49267 |
| Policy instance | 4 |
| Insurance contract or identification number | 49267 | | Number of Individuals Covered | 399 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $35,047 | | Welfare Benefit Premiums Paid to Carrier | USD $407,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,911 | | Insurance broker organization code? | 3 | | Insurance broker name | JUSTIN W. SPEWOCK |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 08865137 |
| Policy instance | 5 |
| Insurance contract or identification number | 08865137 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $1,595 | | Other welfare benefits provided | VOLUNTARY WORKPLACE BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $32,925 | | 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? | 3 | | Insurance broker name | DWIGHT L. PIERCE |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 386 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of fees paid to insurance company | USD $969 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $26,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 969 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 376 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of fees paid to insurance company | USD $2,012 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,630 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2012 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 297 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of fees paid to insurance company | USD $2,681 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,134 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2681 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 268 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of fees paid to insurance company | USD $1,969 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,540 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1969 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0301911 |
| Policy instance | 6 |
| Insurance contract or identification number | R0301911 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $635 | | Other welfare benefits provided | GROUP CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $4,464 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $450 | | Insurance broker organization code? | 3 | | Insurance broker name | DWIGHT L. PIERCE |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 08865137 |
| Policy instance | 5 |
| Insurance contract or identification number | 08865137 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $5,428 | | Other welfare benefits provided | VOLUNTARY WORKPLACE BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $47,326 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $432 | | Insurance broker organization code? | 3 | | Insurance broker name | DWIGHT L. PIERCE |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 49267 |
| Policy instance | 4 |
| Insurance contract or identification number | 49267 | | Number of Individuals Covered | 347 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $25,726 | | Welfare Benefit Premiums Paid to Carrier | USD $312,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,347 | | Insurance broker organization code? | 3 | | Insurance broker name | JUSTIN W. SPEWOCK |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 341 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of fees paid to insurance company | USD $1,475 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1475 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 368 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of fees paid to insurance company | USD $710 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $23,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 710 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 212 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-01-01 | | Total amount of fees paid to insurance company | USD $2,262 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,817 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2262 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 08865137 |
| Policy instance | 5 |
| Insurance contract or identification number | 08865137 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $28,275 | | Total amount of fees paid to insurance company | USD $2,079 | | Other welfare benefits provided | VOLUNTARY WORKPLACE BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $59,644 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,517 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2079 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICES | | Insurance broker name | DWIGHT L. PIERCE |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 49267 |
| Policy instance | 4 |
| Insurance contract or identification number | 49267 | | Number of Individuals Covered | 291 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $65,760 | | Total amount of fees paid to insurance company | USD $5,805 | | Welfare Benefit Premiums Paid to Carrier | USD $289,185 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,111 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 5805 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker name | JUSTIN W. SPEWOCK |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 287 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-01-01 | | Total amount of fees paid to insurance company | USD $873 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $18,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 873 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 274 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-01-01 | | Total amount of fees paid to insurance company | USD $1,642 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,850 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1642 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP, INC. |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 0008865137 |
| Policy instance | 2 |
| Insurance contract or identification number | 0008865137 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $2,267 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | GROUP CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $3,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 49267 |
| Policy instance | 7 |
| Insurance contract or identification number | 49267 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $35,242 | | Welfare Benefit Premiums Paid to Carrier | USD $253,248 | | 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 number | GUG0869J |
| Policy instance | 6 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 208 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $2,907 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,129 | | 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 number | GLUG0869J |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 271 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $1,106 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $19,354 | | 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 number | GLTD0869J |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 266 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $2,412 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,378 | | 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 number | GVTL0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0869J | | Number of Individuals Covered | 116 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $2,977 | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $44,335 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008865137 |
| Policy instance | 1 |
| Insurance contract or identification number | 008865137 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $15,671 | | Total amount of fees paid to insurance company | USD $1,903 | | Other welfare benefits provided | VOLUNTARY WORKPLACE BENEFITS | | Welfare Benefit Premiums Paid to Carrier | USD $22,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 49267 |
| Policy instance | 5 |
| Insurance contract or identification number | 49267 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $59,024 | | Welfare Benefit Premiums Paid to Carrier | USD $255,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,904 | | Insurance broker organization code? | 3 | | Insurance broker name | JUSTIN W SPEWOCK |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0869J |
| Policy instance | 4 |
| Insurance contract or identification number | GUG0869J | | Number of Individuals Covered | 210 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $7,096 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,030 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,096 | | Insurance broker organization code? | 3 | | Insurance broker name | PERFORMAX, INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0869J |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0869J | | Number of Individuals Covered | 273 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $2,649 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $19,816 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,649 | | Insurance broker organization code? | 3 | | Insurance broker name | PERFORMAX, INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0869J |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL0869J | | Number of Individuals Covered | 123 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $7,071 | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $47,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,071 | | Insurance broker organization code? | 3 | | Insurance broker name | PERFORMAX, INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0869J |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0869J | | Number of Individuals Covered | 268 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $5,514 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,761 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,514 | | Insurance broker organization code? | 3 | | Insurance broker name | PERFORMAX, INC |
|
