MEDACUITY, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MEDACUITY LLC GROUP BENEFITS PLAN
2021: MEDACUITY LLC GROUP BENEFITS PLAN 2021 form 5500 responses |
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2021-10-01 | Type of plan entity | Single employer plan |
2021-10-01 | Submission has been amended | No |
2021-10-01 | This submission is the final filing | No |
2021-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-10-01 | Plan is a collectively bargained plan | No |
2021-10-01 | Plan funding arrangement – Insurance | Yes |
2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-10-01 | Plan benefit arrangement – Insurance | Yes |
2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: MEDACUITY LLC GROUP BENEFITS PLAN 2020 form 5500 responses |
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2020-10-01 | Type of plan entity | Single employer plan |
2020-10-01 | Submission has been amended | No |
2020-10-01 | This submission is the final filing | No |
2020-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-10-01 | Plan is a collectively bargained plan | No |
2020-10-01 | Plan funding arrangement – Insurance | Yes |
2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-10-01 | Plan benefit arrangement – Insurance | Yes |
2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: MEDACUITY LLC GROUP BENEFITS PLAN 2019 form 5500 responses |
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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 | No |
2019-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
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: MEDACUITY LLC GROUP BENEFITS PLAN 2018 form 5500 responses |
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2018-10-01 | Type of plan entity | Single employer plan |
2018-10-01 | First time form 5500 has been submitted | Yes |
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 |
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10189991001 |
Policy instance | 5 |
Insurance contract or identification number | 10189991001 | Number of Individuals Covered | 84 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $1,285 | Total amount of fees paid to insurance company | USD $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 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 | Yes | 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 $12,043 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,285 | Insurance broker organization code? | 3 |
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TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
Policy contract number | 44218 44516 |
Policy instance | 4 |
Insurance contract or identification number | 44218 44516 | Number of Individuals Covered | 111 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $20,953 | Total amount of fees paid to insurance company | USD $4,575 | 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 | Yes | 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 $712,797 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,953 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 4575 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 889106G |
Policy instance | 3 |
Insurance contract or identification number | 889106G | Number of Individuals Covered | 114 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $8,668 | Total amount of fees paid to insurance company | USD $6,451 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $69,691 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,668 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 4878 | Additional information about fees paid to insurance broker | SERVICE FEE |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 60795 |
Policy instance | 2 |
Insurance contract or identification number | 60795 | Number of Individuals Covered | 103 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $16,802 | Total amount of fees paid to insurance company | USD $5,207 | 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 $548,818 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $16,802 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 5207 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS |
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BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 8050577 |
Policy instance | 1 |
Insurance contract or identification number | 8050577 | Number of Individuals Covered | 94 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $5,183 | Total amount of fees paid to insurance company | USD $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 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 | Yes | 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 $88,141 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,183 | Insurance broker organization code? | 3 |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 60795 |
Policy instance | 2 |
Insurance contract or identification number | 60795 | Number of Individuals Covered | 124 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $22,190 | Total amount of fees paid to insurance company | USD $9,898 | 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 $739,348 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $22,190 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 9898 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 889106G |
Policy instance | 3 |
Insurance contract or identification number | 889106G | Number of Individuals Covered | 123 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $11,577 | Total amount of fees paid to insurance company | USD $9,253 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $92,574 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,577 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 6480 | Additional information about fees paid to insurance broker | SERVICE FEE |
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TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
Policy contract number | 44218 44516 |
Policy instance | 4 |
Insurance contract or identification number | 44218 44516 | Number of Individuals Covered | 90 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $17,130 | Total amount of fees paid to insurance company | USD $6,758 | 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 | Yes | 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 $577,427 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,130 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 6758 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10189991001 |
Policy instance | 5 |
Insurance contract or identification number | 10189991001 | Number of Individuals Covered | 187 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $1,285 | Total amount of fees paid to insurance company | USD $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 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 | Yes | 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 $12,043 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,285 | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 8050577 |
Policy instance | 1 |
Insurance contract or identification number | 8050577 | Number of Individuals Covered | 99 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $4,194 | Total amount of fees paid to insurance company | USD $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 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 | Yes | 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? | Yes | Welfare Benefit Premiums Paid to Carrier | USD $89,892 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,194 | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10189991001 |
Policy instance | 5 |
Insurance contract or identification number | 10189991001 | Number of Individuals Covered | 117 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $1,037 | Total amount of fees paid to insurance company | USD $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 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 | Yes | 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 $10,489 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $755 | Insurance broker organization code? | 3 |
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TUFTS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60117 ) |
Policy contract number | 44218 44516 |
Policy instance | 4 |
Insurance contract or identification number | 44218 44516 | Number of Individuals Covered | 40 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $12,277 | Total amount of fees paid to insurance company | USD $1,401 | 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 | Yes | 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 $448,298 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,277 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 1401 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 889106G |
Policy instance | 3 |
Insurance contract or identification number | 889106G | Number of Individuals Covered | 119 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $8,361 | Total amount of fees paid to insurance company | USD $8,863 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $69,502 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,361 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 4865 | Additional information about fees paid to insurance broker | SERVICE FEE |
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TUFTS ASSOCIATED HEALTH MAINTENANCE ORG., INC. (National Association of Insurance Commissioners NAIC id number: 95688 ) |
Policy contract number | 60795 |
Policy instance | 2 |
Insurance contract or identification number | 60795 | Number of Individuals Covered | 60 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $18,634 | Total amount of fees paid to insurance company | USD $2,056 | 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 $680,486 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,634 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 2056 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS |
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BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 8050577 |
Policy instance | 1 |
Insurance contract or identification number | 8050577 | Number of Individuals Covered | 94 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $3,409 | Total amount of fees paid to insurance company | USD $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 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 | Yes | 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 $78,971 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Insurance broker organization code? | 3 | Commission paid to Insurance Broker | USD $3,409 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD609831 |
Policy instance | 2 |
Insurance contract or identification number | SGD609831 | Number of Individuals Covered | 79 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,395 | Total amount of fees paid to insurance company | USD $258 | 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 | Yes | 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 $12,793 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,199 | Amount paid for insurance broker fees | 258 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD609831 |
Policy instance | 3 |
Insurance contract or identification number | SGD609831 | Number of Individuals Covered | 79 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,836 | Total amount of fees paid to insurance company | USD $327 | 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 | Yes | 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 $12,237 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,437 | Amount paid for insurance broker fees | 327 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
Policy contract number | 8051577 |
Policy instance | 4 |
Insurance contract or identification number | 8051577 | Number of Individuals Covered | 74 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $23,773 | Total amount of fees paid to insurance company | USD $2,320 | 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 | Yes | 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 $835,339 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,900 | Amount paid for insurance broker fees | 2320 | Additional information about fees paid to insurance broker | NON-EXPERIENCED RATED BONUS | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD609831 |
Policy instance | 5 |
Insurance contract or identification number | SGD609831 | Number of Individuals Covered | 83 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,193 | Total amount of fees paid to insurance company | USD $215 | 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 | Yes | 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 $11,937 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $929 | Amount paid for insurance broker fees | 215 | Additional information about fees paid to insurance broker | NON-EXPERIENCE RATED BONUS | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10189991001 |
Policy instance | 6 |
Insurance contract or identification number | 10189991001 | Number of Individuals Covered | 146 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $872 | Total amount of fees paid to insurance company | USD $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 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 | Yes | 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 $8,095 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $637 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 3342179 |
Policy instance | 1 |
Insurance contract or identification number | 3342179 | Number of Individuals Covered | 82 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $3,303 | Total amount of fees paid to insurance company | USD $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 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 | Yes | 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 $66,668 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,106 | Insurance broker organization code? | 3 |
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