UNITED COLLECTION BUREAU, INC. AND SUBSIDIARIES has sponsored the creation of one or more 401k plans.
Additional information about UNITED COLLECTION BUREAU, INC. AND SUBSIDIARIES
Submission information for form 5500 for 401k plan UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN
401k plan membership statisitcs for UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN
| Measure | Date | Value |
|---|
| 2022: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 387 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 328 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 1 |
| Total of all active and inactive participants | 2022-01-01 | 329 |
| 2021: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 407 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 387 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 1 |
| Total of all active and inactive participants | 2021-01-01 | 388 |
| 2020: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 657 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 407 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 4 |
| Total of all active and inactive participants | 2020-01-01 | 411 |
| 2019: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 711 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 657 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 4 |
| Total of all active and inactive participants | 2019-01-01 | 661 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Number of employers contributing to the scheme | 2019-01-01 | 20 |
| 2018: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 635 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 711 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| 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 | 711 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 647 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 633 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 2 |
| Total of all active and inactive participants | 2017-01-01 | 635 |
| 2016: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 627 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 647 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 2 |
| Total of all active and inactive participants | 2016-01-01 | 649 |
| 2015: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 649 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 627 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 1 |
| Total of all active and inactive participants | 2015-01-01 | 628 |
| 2014: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 685 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 649 |
| Total of all active and inactive participants | 2014-01-01 | 649 |
| 2013: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 880 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 684 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 1 |
| Total of all active and inactive participants | 2013-01-01 | 685 |
| 2012: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 855 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 879 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 1 |
| Total of all active and inactive participants | 2012-01-01 | 880 |
| 2011: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-04-01 | 837 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-04-01 | 853 |
| Number of retired or separated participants receiving benefits | 2011-04-01 | 2 |
| Total of all active and inactive participants | 2011-04-01 | 855 |
| 2010: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-04-01 | 818 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-04-01 | 833 |
| Number of retired or separated participants receiving benefits | 2010-04-01 | 4 |
| Total of all active and inactive participants | 2010-04-01 | 837 |
| 2009: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-04-01 | 802 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-04-01 | 809 |
| Number of retired or separated participants receiving benefits | 2009-04-01 | 9 |
| Total of all active and inactive participants | 2009-04-01 | 818 |
| 2022: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | Yes |
| 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: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2011 form 5500 responses |
|---|
| 2011-04-01 | Type of plan entity | Single employer plan |
| 2011-04-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2011-04-01 | Plan funding arrangement – Insurance | Yes |
| 2011-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2010 form 5500 responses |
|---|
| 2010-04-01 | Type of plan entity | Single employer plan |
| 2010-04-01 | Plan funding arrangement – Insurance | Yes |
| 2010-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: UNITED COLLECTION BUREAU, INC. GROUP INSURANCE PLAN 2009 form 5500 responses |
|---|
| 2009-04-01 | Type of plan entity | Single employer plan |
| 2009-04-01 | This submission is the final filing | No |
| 2009-04-01 | Plan funding arrangement – Insurance | Yes |
| 2009-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 168258 |
| Policy instance | 8 |
| Insurance contract or identification number | 168258 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,852 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,852 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 8 |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 1 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 328 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,719 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,719 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 168258 |
| Policy instance | 2 |
| Insurance contract or identification number | 168258 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $18,505 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $68,876 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,505 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 3 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,464 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,464 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | AFA-P21-1240 |
| Policy instance | 4 |
| Insurance contract or identification number | AFA-P21-1240 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $21,023 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $420,405 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,513 | | Insurance broker organization code? | 3 |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | OTP01234-22 |
| Policy instance | 5 |
| Insurance contract or identification number | OTP01234-22 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,933 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $29,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,933 | | Insurance broker organization code? | 5 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 168258 |
| Policy instance | 6 |
| Insurance contract or identification number | 168258 | | Number of Individuals Covered | 327 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,763 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,763 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 168258 |
| Policy instance | 7 |
| Insurance contract or identification number | 168258 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,722 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,722 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,536 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,536 | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10257387 |
| Policy instance | 3 |
| Insurance contract or identification number | 10257387 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,002 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,002 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 376 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,410 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,410 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | AFA-P21-1240 |
| Policy instance | 5 |
| Insurance contract or identification number | AFA-P21-1240 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $35,358 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $471,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,572 | | Insurance broker organization code? | 5 |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 378 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $548,852 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 407 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,573 | | Total amount of fees paid to insurance company | USD $241 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $920 | | Amount paid for insurance broker fees | 241 | | Additional information about fees paid to insurance broker | NEW BUSINESS BONUS, RETENTION BONUS | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10257387 |
| Policy instance | 3 |
| Insurance contract or identification number | 10257387 | | Number of Individuals Covered | 349 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $993 | | Total amount of fees paid to insurance company | USD $529 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,926 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $626 | | Amount paid for insurance broker fees | 529 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,851 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,863 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $934 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 241979 |
| Policy instance | 1 |
| Insurance contract or identification number | 241979 | | Number of Individuals Covered | 657 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,906 | | Total amount of fees paid to insurance company | USD $903 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,906 | | Amount paid for insurance broker fees | 903 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 9498 |
| Policy instance | 2 |
| Insurance contract or identification number | 9498 | | Number of Individuals Covered | 427 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,143 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,143 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 3 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 361 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,573 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,213 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,573 | | Insurance broker organization code? | 3 |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 411 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $460,471 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 6 |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 427 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,143 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,143 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 241979 |
| Policy instance | 3 |
| Insurance contract or identification number | 241979 | | Number of Individuals Covered | 657 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,906 | | Total amount of fees paid to insurance company | USD $903 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,906 | | Amount paid for insurance broker fees | 903 | | Additional information about fees paid to insurance broker | BONUS PAID TO PRODUCER FOR PERIOD 1/1/2018 TO 12/31/2018 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 361 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,573 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,213 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,573 | | Insurance broker organization code? | 3 |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 462 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,565 | | Welfare Benefit Premiums Paid to Carrier | USD $616,119 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1565 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 241979 |
| Policy instance | 3 |
| Insurance contract or identification number | 241979 | | Number of Individuals Covered | 711 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,547 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $12,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,547 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 478 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,148 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,148 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 597 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,952 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,856 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,952 | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 3 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 597 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,952 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,856 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,952 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 9498 |
| Policy instance | 2 |
| Insurance contract or identification number | 9498 | | Number of Individuals Covered | 478 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,148 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,148 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 241979 |
| Policy instance | 1 |
| Insurance contract or identification number | 241979 | | Number of Individuals Covered | 711 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,479 | | Total amount of fees paid to insurance company | USD $1,068 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,479 | | Amount paid for insurance broker fees | 1068 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 633 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,828 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,660 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,828 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 241979 |
| Policy instance | 3 |
| Insurance contract or identification number | 241979 | | Number of Individuals Covered | 473 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,294 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,798 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,444 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 497 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,800 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 457 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $573,992 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $492,298 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 554 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,006 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,006 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOKS INSURANCE AGENCY |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00123668 |
| Policy instance | 3 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 505 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,311 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,094 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,311 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOK INSURANCE AGENCY INC |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 627 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,159 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,159 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOK INSURANCE AGENCY INC |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 333 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $29,951 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $511,021 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,951 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOKS INSURANCE AGENCY INC |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00123668 |
| Policy instance | 3 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 540 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,477 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,592 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,477 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOK INSURANCE AGENCY INC |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 649 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,925 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,220 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,925 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOK INSURANCE AGENCY INC |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 599 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,635 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,635 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOKS INSURANCE AGENCY |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 402 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $66,279 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $511,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,279 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOKS INSURANCE AGENCY INC |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00123668 |
| Policy instance | 3 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 608 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,128 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $16,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,948 | | Insurance broker name | BENEFIT ADVISORS SERVICE GROUP LLC |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 684 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,798 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,387 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,798 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOK INSURANCE AGENCY INC |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 664 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,369 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,369 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOKS INSURANCE AGENCY |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30497 |
| Policy instance | 4 |
| Insurance contract or identification number | 30497 | | Number of Individuals Covered | 873 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,608 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,752 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,608 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOK INSURANCE AGENCY INC |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00123668 |
| Policy instance | 3 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 794 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,145 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $27,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,145 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOK INSURANCE AGENCY INC |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 879 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $5,995 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,995 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOKS INSURANCE AGENCY |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 544 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $95,731 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $513,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $95,731 | | Insurance broker organization code? | 3 | | Insurance broker name | BROOKS INSURANCE AGENCY INC |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 5 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 581 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $130,707 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00123668 |
| Policy instance | 4 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 825 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $681 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $6,814 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00123668 |
| Policy instance | 3 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 777 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $2,786 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $29,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 853 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $5,310 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 565 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $439,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00123668 |
| Policy instance | 1 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 560 | | Insurance policy start date | 2009-10-01 | | Insurance policy end date | 2010-09-30 | | Total amount of commissions paid to insurance broker | USD $83,323 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $355,013 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 009498 |
| Policy instance | 2 |
| Insurance contract or identification number | 009498 | | Number of Individuals Covered | 833 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $6,485 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00123668 |
| Policy instance | 3 |
| Insurance contract or identification number | 00123668 | | Number of Individuals Covered | 765 | | Insurance policy start date | 2009-10-01 | | Insurance policy end date | 2010-09-30 | | Total amount of commissions paid to insurance broker | USD $2,557 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $27,634 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
