JACKSON COUNTY BANK has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan JACKSON COUNTY BANK GROUP INSURANCE PLAN
Measure | Date | Value |
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2022: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-05-01 | 152 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-05-01 | 158 |
Number of retired or separated participants receiving benefits | 2022-05-01 | 24 |
Number of other retired or separated participants entitled to future benefits | 2022-05-01 | 0 |
Total of all active and inactive participants | 2022-05-01 | 182 |
2021: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-05-01 | 145 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-05-01 | 129 |
Number of retired or separated participants receiving benefits | 2021-05-01 | 23 |
Total of all active and inactive participants | 2021-05-01 | 152 |
Total participants | 2021-05-01 | 152 |
2020: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-05-01 | 144 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-05-01 | 124 |
Number of retired or separated participants receiving benefits | 2020-05-01 | 24 |
Total of all active and inactive participants | 2020-05-01 | 148 |
Total participants | 2020-05-01 | 148 |
2019: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-05-01 | 137 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 121 |
Number of retired or separated participants receiving benefits | 2019-05-01 | 23 |
Total of all active and inactive participants | 2019-05-01 | 144 |
Total participants | 2019-05-01 | 144 |
2018: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-05-01 | 114 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 115 |
Number of retired or separated participants receiving benefits | 2018-05-01 | 22 |
Total of all active and inactive participants | 2018-05-01 | 137 |
Total participants | 2018-05-01 | 137 |
2017: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-05-01 | 123 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 94 |
Number of retired or separated participants receiving benefits | 2017-05-01 | 20 |
Total of all active and inactive participants | 2017-05-01 | 114 |
Total participants | 2017-05-01 | 114 |
2016: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-05-01 | 118 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 103 |
Number of retired or separated participants receiving benefits | 2016-05-01 | 20 |
Total of all active and inactive participants | 2016-05-01 | 123 |
Total participants | 2016-05-01 | 123 |
2015: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-05-01 | 125 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 96 |
Number of retired or separated participants receiving benefits | 2015-05-01 | 22 |
Total of all active and inactive participants | 2015-05-01 | 118 |
Total participants | 2015-05-01 | 118 |
2014: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-05-01 | 125 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-05-01 | 101 |
Number of retired or separated participants receiving benefits | 2014-05-01 | 24 |
Total of all active and inactive participants | 2014-05-01 | 125 |
Total participants | 2014-05-01 | 125 |
2013: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-05-01 | 122 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 101 |
Number of retired or separated participants receiving benefits | 2013-05-01 | 24 |
Total of all active and inactive participants | 2013-05-01 | 125 |
Total participants | 2013-05-01 | 125 |
2012: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-05-01 | 124 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 98 |
Number of retired or separated participants receiving benefits | 2012-05-01 | 24 |
Total of all active and inactive participants | 2012-05-01 | 122 |
Total participants | 2012-05-01 | 122 |
2011: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-05-01 | 128 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 99 |
Number of retired or separated participants receiving benefits | 2011-05-01 | 25 |
Total of all active and inactive participants | 2011-05-01 | 124 |
Total participants | 2011-05-01 | 124 |
2010: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2010 401k membership |
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Total participants, beginning-of-year | 2010-05-01 | 139 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-05-01 | 102 |
Number of retired or separated participants receiving benefits | 2010-05-01 | 26 |
Total of all active and inactive participants | 2010-05-01 | 128 |
Total participants | 2010-05-01 | 128 |
2008: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2008 401k membership |
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Total participants, beginning-of-year | 2008-11-01 | 145 |
Total number of active participants reported on line 7a of the Form 5500 | 2008-11-01 | 133 |
Number of retired or separated participants receiving benefits | 2008-11-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2008-11-01 | 0 |
Total of all active and inactive participants | 2008-11-01 | 133 |
Total participants | 2008-11-01 | 133 |
2022: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2022 form 5500 responses |
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2022-05-01 | Type of plan entity | Single employer plan |
2022-05-01 | Submission has been amended | No |
2022-05-01 | This submission is the final filing | No |
2022-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-05-01 | Plan is a collectively bargained plan | No |
2022-05-01 | Plan funding arrangement – Insurance | Yes |
2022-05-01 | Plan benefit arrangement – Insurance | Yes |
2021: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2021 form 5500 responses |
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2021-05-01 | Type of plan entity | Single employer plan |
2021-05-01 | Submission has been amended | No |
2021-05-01 | This submission is the final filing | No |
2021-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-05-01 | Plan is a collectively bargained plan | No |
2021-05-01 | Plan funding arrangement – Insurance | Yes |
2021-05-01 | Plan benefit arrangement – Insurance | Yes |
2020: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2020 form 5500 responses |
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2020-05-01 | Type of plan entity | Single employer plan |
2020-05-01 | Submission has been amended | No |
2020-05-01 | This submission is the final filing | No |
2020-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-05-01 | Plan is a collectively bargained plan | No |
2020-05-01 | Plan funding arrangement – Insurance | Yes |
2020-05-01 | Plan benefit arrangement – Insurance | Yes |
2019: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2019 form 5500 responses |
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2019-05-01 | Type of plan entity | Single employer plan |
2019-05-01 | Submission has been amended | No |
2019-05-01 | This submission is the final filing | No |
2019-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-05-01 | Plan is a collectively bargained plan | No |
2019-05-01 | Plan funding arrangement – Insurance | Yes |
2019-05-01 | Plan benefit arrangement – Insurance | Yes |
2018: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2018 form 5500 responses |
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2018-05-01 | Type of plan entity | Single employer plan |
2018-05-01 | Submission has been amended | No |
2018-05-01 | This submission is the final filing | No |
2018-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-05-01 | Plan is a collectively bargained plan | No |
2018-05-01 | Plan funding arrangement – Insurance | Yes |
2018-05-01 | Plan benefit arrangement – Insurance | Yes |
2017: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2017 form 5500 responses |
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2017-05-01 | Type of plan entity | Single employer plan |
2017-05-01 | Submission has been amended | No |
2017-05-01 | This submission is the final filing | No |
2017-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-05-01 | Plan is a collectively bargained plan | No |
2017-05-01 | Plan funding arrangement – Insurance | Yes |
2017-05-01 | Plan benefit arrangement – Insurance | Yes |
2016: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2016 form 5500 responses |
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2016-05-01 | Type of plan entity | Single employer plan |
2016-05-01 | Submission has been amended | No |
2016-05-01 | This submission is the final filing | No |
2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-05-01 | Plan is a collectively bargained plan | No |
2016-05-01 | Plan funding arrangement – Insurance | Yes |
2016-05-01 | Plan benefit arrangement – Insurance | Yes |
2015: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2015 form 5500 responses |
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2015-05-01 | Type of plan entity | Single employer plan |
2015-05-01 | Submission has been amended | No |
2015-05-01 | This submission is the final filing | No |
2015-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-05-01 | Plan is a collectively bargained plan | No |
2015-05-01 | Plan funding arrangement – Insurance | Yes |
2015-05-01 | Plan benefit arrangement – Insurance | Yes |
2014: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2014 form 5500 responses |
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2014-05-01 | Type of plan entity | Single employer plan |
2014-05-01 | Submission has been amended | No |
2014-05-01 | This submission is the final filing | No |
2014-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-05-01 | Plan is a collectively bargained plan | No |
2014-05-01 | Plan funding arrangement – Insurance | Yes |
2014-05-01 | Plan benefit arrangement – Insurance | Yes |
2013: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2013 form 5500 responses |
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2013-05-01 | Type of plan entity | Single employer plan |
2013-05-01 | Submission has been amended | No |
2013-05-01 | This submission is the final filing | No |
2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-05-01 | Plan is a collectively bargained plan | No |
2013-05-01 | Plan funding arrangement – Insurance | Yes |
2013-05-01 | Plan benefit arrangement – Insurance | Yes |
2012: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2012 form 5500 responses |
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2012-05-01 | Type of plan entity | Single employer plan |
2012-05-01 | Submission has been amended | No |
2012-05-01 | This submission is the final filing | No |
2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-05-01 | Plan is a collectively bargained plan | No |
2012-05-01 | Plan funding arrangement – Insurance | Yes |
2012-05-01 | Plan benefit arrangement – Insurance | Yes |
2011: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2011 form 5500 responses |
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2011-05-01 | Type of plan entity | Single employer plan |
2011-05-01 | Submission has been amended | No |
2011-05-01 | This submission is the final filing | No |
2011-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-05-01 | Plan is a collectively bargained plan | No |
2011-05-01 | Plan funding arrangement – Insurance | Yes |
2011-05-01 | Plan benefit arrangement – Insurance | Yes |
2010: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2010 form 5500 responses |
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2010-05-01 | Type of plan entity | Single employer plan |
2010-05-01 | Submission has been amended | No |
2010-05-01 | This submission is the final filing | No |
2010-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2010-05-01 | Plan is a collectively bargained plan | No |
2010-05-01 | Plan funding arrangement – Insurance | Yes |
2010-05-01 | Plan benefit arrangement – Insurance | Yes |
2008: JACKSON COUNTY BANK GROUP INSURANCE PLAN 2008 form 5500 responses |
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2008-11-01 | Type of plan entity | Single employer plan |
2008-11-01 | Submission has been amended | No |
2008-11-01 | This submission is the final filing | No |
2008-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2008-11-01 | Plan is a collectively bargained plan | No |
2008-11-01 | Plan funding arrangement – Insurance | Yes |
SIHO (National Association of Insurance Commissioners NAIC id number: 95812 ) |
Policy contract number | 101193 |
Policy instance | 6 |
Insurance contract or identification number | 101193 | Number of Individuals Covered | 187 | Insurance policy start date | 2022-05-01 | Insurance policy end date | 2023-04-30 | Total amount of commissions paid to insurance broker | USD $32,947 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,121,540 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $32,947 | Insurance broker organization code? | 3 |
|
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BNGH |
Policy instance | 7 |
Insurance contract or identification number | GLUG0BNGH | Number of Individuals Covered | 182 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $3,771 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $45,412 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,771 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 10157 |
Policy instance | 1 |
Insurance contract or identification number | 10157 | Number of Individuals Covered | 205 | Insurance policy start date | 2022-05-01 | Insurance policy end date | 2023-04-30 | Total amount of commissions paid to insurance broker | USD $4,362 | 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 $4,362 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30025862 |
Policy instance | 2 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 103 | Insurance policy start date | 2022-05-01 | Insurance policy end date | 2023-04-30 | Total amount of commissions paid to insurance broker | USD $828 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $14,794 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $828 | Insurance broker organization code? | 3 |
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ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 3 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 135 | Insurance policy start date | 2021-11-01 | Insurance policy end date | 2022-10-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $2,634 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BNGH |
Policy instance | 4 |
Insurance contract or identification number | GVTL0BNGH | Number of Individuals Covered | 57 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $2,735 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $18,230 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,735 | Insurance broker organization code? | 3 |
|
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BNGH |
Policy instance | 5 |
Insurance contract or identification number | GLTD0BNGH | Number of Individuals Covered | 159 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $2,816 | Total amount of fees paid to insurance company | USD $0 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $20,661 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,816 | Insurance broker organization code? | 3 |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30025862 |
Policy instance | 3 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 91 | Insurance policy start date | 2021-05-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $878 | 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 $13,570 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $878 | Insurance broker organization code? | 3 |
|
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BNGH |
Policy instance | 1 |
Insurance contract or identification number | G000BNGH | Number of Individuals Covered | 152 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2022-01-01 | Total amount of commissions paid to insurance broker | USD $8,458 | 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 | No | Life Insurance Welfare Benefit | Yes | 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 $75,545 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,458 | Insurance broker organization code? | 3 |
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ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 2 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 135 | Insurance policy start date | 2020-11-01 | Insurance policy end date | 2021-10-31 | Total amount of commissions paid to insurance broker | USD $0 | 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 | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,747 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 10157 |
Policy instance | 4 |
Insurance contract or identification number | 10157 | Number of Individuals Covered | 165 | Insurance policy start date | 2021-05-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $2,410 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,410 | Insurance broker organization code? | 3 |
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SIHO (National Association of Insurance Commissioners NAIC id number: 95812 ) |
Policy contract number | 101193 |
Policy instance | 5 |
Insurance contract or identification number | 101193 | Number of Individuals Covered | 97 | Insurance policy start date | 2021-07-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $25,402 | 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 | 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 $911,547 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $25,402 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30025862 |
Policy instance | 3 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 85 | Insurance policy start date | 2020-05-01 | Insurance policy end date | 2021-04-30 | Total amount of commissions paid to insurance broker | USD $859 | 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 $13,047 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $859 | Insurance broker organization code? | 3 |
|
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BNGH |
Policy instance | 1 |
Insurance contract or identification number | G000BNGH | Number of Individuals Covered | 146 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2021-01-01 | Total amount of commissions paid to insurance broker | USD $7,022 | 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 | No | Life Insurance Welfare Benefit | Yes | 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 $62,447 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,022 | Insurance broker organization code? | 3 |
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ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 2 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 133 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2020-10-31 | Total amount of commissions paid to insurance broker | USD $0 | 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 | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,696 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 2 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 128 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $0 | 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 | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,577 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 136 |
Policy instance | 4 |
Insurance contract or identification number | 136 | Number of Individuals Covered | 86 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2020-04-30 | Total amount of commissions paid to insurance broker | USD $2,266 | 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 $57,870 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,266 | Insurance broker organization code? | 3 |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30025862 |
Policy instance | 3 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 85 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2020-04-30 | Total amount of commissions paid to insurance broker | USD $855 | 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 $12,974 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $855 | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 139692 |
Policy instance | 1 |
Insurance contract or identification number | 139692 | Number of Individuals Covered | 144 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2020-01-01 | Total amount of commissions paid to insurance broker | USD $5,725 | 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 | No | Life Insurance Welfare Benefit | Yes | 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 $54,564 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,725 | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 139692 |
Policy instance | 1 |
Insurance contract or identification number | 139692 | Number of Individuals Covered | 137 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $5,039 | 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 | No | Life Insurance Welfare Benefit | Yes | 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 $52,625 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,039 | Insurance broker organization code? | 3 |
|
ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 2 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 118 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $0 | 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 | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,414 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30025862 |
Policy instance | 3 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 73 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $783 | 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 $10,915 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $783 | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 139692 |
Policy instance | 1 |
Insurance contract or identification number | 139692 | Number of Individuals Covered | 114 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $5,148 | 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 | 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 $48,083 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,148 | Insurance broker organization code? | 3 | Insurance broker name | ERTLE & COMPANY, INC. |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30025862 |
Policy instance | 3 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 71 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $785 | 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 $10,985 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $785 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 136 |
Policy instance | 4 |
Insurance contract or identification number | 136 | Number of Individuals Covered | 76 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $1,925 | 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 | 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 | ERTEL & COMPANY, INC. |
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ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 2 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 120 | Insurance policy start date | 2016-11-01 | Insurance policy end date | 2017-10-31 | Total amount of commissions paid to insurance broker | USD $0 | 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 | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,426 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
Policy contract number | 30025862 |
Policy instance | 5 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 65 | Insurance policy start date | 2015-05-01 | Insurance policy end date | 2016-04-30 | Total amount of commissions paid to insurance broker | USD $753 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $10,084 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $753 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 136 |
Policy instance | 4 |
Insurance contract or identification number | 136 | Number of Individuals Covered | 65 | Insurance policy start date | 2015-05-01 | Insurance policy end date | 2016-04-30 | Total amount of commissions paid to insurance broker | USD $1,692 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,692 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
Policy contract number | 000007197 |
Policy instance | 3 |
Insurance contract or identification number | 000007197 | Number of Individuals Covered | 61 | Insurance policy start date | 2015-05-01 | Insurance policy end date | 2016-04-30 | Total amount of commissions paid to insurance broker | USD $14,820 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | 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 $574,023 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,340 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 139692 |
Policy instance | 2 |
Insurance contract or identification number | 139692 | Number of Individuals Covered | 118 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $4,481 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | 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 $42,094 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,481 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 1 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 112 | Insurance policy start date | 2014-11-01 | Insurance policy end date | 2015-10-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,304 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 1 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 113 | Insurance policy start date | 2013-11-01 | Insurance policy end date | 2014-10-01 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,285 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 139692 |
Policy instance | 2 |
Insurance contract or identification number | 139692 | Number of Individuals Covered | 125 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $4,378 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | 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 $44,387 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,378 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
|
ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
Policy contract number | 000007197 |
Policy instance | 3 |
Insurance contract or identification number | 000007197 | Number of Individuals Covered | 68 | Insurance policy start date | 2014-05-01 | Insurance policy end date | 2015-04-30 | Total amount of commissions paid to insurance broker | USD $13,433 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | 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 $506,746 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,312 | Insurance broker organization code? | 3 | Insurance broker name | IMASERV INC. |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 136 |
Policy instance | 4 |
Insurance contract or identification number | 136 | Number of Individuals Covered | 69 | Insurance policy start date | 2014-05-01 | Insurance policy end date | 2015-04-30 | Total amount of commissions paid to insurance broker | USD $1,732 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,732 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
Policy contract number | 30025862 |
Policy instance | 5 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 73 | Insurance policy start date | 2014-05-01 | Insurance policy end date | 2015-04-30 | Total amount of commissions paid to insurance broker | USD $698 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $8,959 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $698 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
Policy contract number | 000007197 |
Policy instance | 3 |
Insurance contract or identification number | 000007197 | Number of Individuals Covered | 65 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2014-04-30 | Total amount of commissions paid to insurance broker | USD $15,314 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | 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 $572,166 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,418 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 136 |
Policy instance | 5 |
Insurance contract or identification number | 136 | Number of Individuals Covered | 60 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2014-04-30 | Total amount of commissions paid to insurance broker | USD $1,764 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,764 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
Policy contract number | 30025862 |
Policy instance | 4 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 65 | Insurance policy start date | 2013-05-01 | Insurance policy end date | 2014-04-30 | Total amount of commissions paid to insurance broker | USD $691 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $8,820 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $691 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 139692 |
Policy instance | 2 |
Insurance contract or identification number | 139692 | Number of Individuals Covered | 125 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $4,297 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | 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 $36,844 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,297 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 1 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 114 | Insurance policy start date | 2012-11-01 | Insurance policy end date | 2013-10-31 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,334 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
Policy contract number | 000007197 |
Policy instance | 3 |
Insurance contract or identification number | 000007197 | Number of Individuals Covered | 72 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $15,903 | Total amount of fees paid to insurance company | USD $915 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $467,802 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,392 | Amount paid for insurance broker fees | 915 | Insurance broker organization code? | 3 | Insurance broker name | IMASERV INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
Policy contract number | 30025862 |
Policy instance | 4 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 68 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $666 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,314 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $666 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY, INC. |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 136 |
Policy instance | 5 |
Insurance contract or identification number | 136 | Number of Individuals Covered | 57 | Insurance policy start date | 2012-05-01 | Insurance policy end date | 2013-04-30 | Total amount of commissions paid to insurance broker | USD $1,403 | 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 $1,403 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY INC |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 139692 |
Policy instance | 2 |
Insurance contract or identification number | 139692 | Number of Individuals Covered | 122 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $3,379 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $33,384 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,379 | Insurance broker organization code? | 3 | Insurance broker name | ERTEL & COMPANY INC |
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ADVANTAGE BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 1 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 117 | Insurance policy start date | 2011-11-01 | Insurance policy end date | 2012-10-31 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $2,364 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
Policy contract number | 136 |
Policy instance | 4 |
Insurance contract or identification number | 136 | Number of Individuals Covered | 60 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $1,415 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $38,621 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
Policy contract number | 30025862 |
Policy instance | 5 |
Insurance contract or identification number | 30025862 | Number of Individuals Covered | 60 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $611 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $7,216 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
Policy contract number | 10215 |
Policy instance | 3 |
Insurance contract or identification number | 10215 | Number of Individuals Covered | 77 | Insurance policy start date | 2011-05-01 | Insurance policy end date | 2012-04-30 | Total amount of commissions paid to insurance broker | USD $16,701 | Total amount of fees paid to insurance company | USD $248 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $446,674 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 139692 |
Policy instance | 2 |
Insurance contract or identification number | 139692 | Number of Individuals Covered | 124 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $3,446 | Health Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $29,957 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CENTERSTONE INDIANA (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 1 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 120 | Insurance policy start date | 2010-11-01 | Insurance policy end date | 2011-10-31 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $2,428 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
Policy contract number | 00010215 |
Policy instance | 3 |
Insurance contract or identification number | 00010215 | Number of Individuals Covered | 72 | Insurance policy start date | 2010-05-01 | Insurance policy end date | 2011-04-30 | Total amount of commissions paid to insurance broker | USD $17,005 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $363,792 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00437235 |
Policy instance | 4 |
Insurance contract or identification number | 00437235 | Number of Individuals Covered | 66 | Insurance policy start date | 2010-05-01 | Insurance policy end date | 2011-04-30 | Total amount of commissions paid to insurance broker | USD $2,577 | Total amount of fees paid to insurance company | USD $907 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $42,025 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00437235 |
Policy instance | 5 |
Insurance contract or identification number | 00437235 | Number of Individuals Covered | 66 | Insurance policy start date | 2010-05-01 | Insurance policy end date | 2011-04-30 | Total amount of commissions paid to insurance broker | USD $845 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,370 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 000000139692 |
Policy instance | 2 |
Insurance contract or identification number | 000000139692 | Number of Individuals Covered | 128 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $3,663 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $31,532 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CENTERSTONE INDIANA (National Association of Insurance Commissioners NAIC id number: 62112 ) |
Policy contract number | 8125 |
Policy instance | 1 |
Insurance contract or identification number | 8125 | Number of Individuals Covered | 120 | Insurance policy start date | 2009-11-01 | Insurance policy end date | 2010-10-31 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $2,587 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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