IMMI HOLDINGS, INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN
401k plan membership statisitcs for INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 570 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 533 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 533 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 909 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 570 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 570 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 608 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 909 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 909 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 474 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 608 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 608 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 463 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 474 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 474 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 418 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 461 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 463 |
| 2016: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 443 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 418 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 418 |
| 2015: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 460 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 442 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 443 |
| 2014: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-02-01 | 421 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-02-01 | 459 |
| Number of retired or separated participants receiving benefits | 2014-02-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2014-02-01 | 0 |
| Total of all active and inactive participants | 2014-02-01 | 462 |
| 2013: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-02-01 | 443 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-02-01 | 419 |
| Number of retired or separated participants receiving benefits | 2013-02-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2013-02-01 | 0 |
| Total of all active and inactive participants | 2013-02-01 | 421 |
| 2012: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-02-01 | 433 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-02-01 | 442 |
| Number of retired or separated participants receiving benefits | 2012-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2012-02-01 | 0 |
| Total of all active and inactive participants | 2012-02-01 | 443 |
| 2011: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-02-01 | 422 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-02-01 | 429 |
| Number of retired or separated participants receiving benefits | 2011-02-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2011-02-01 | 0 |
| Total of all active and inactive participants | 2011-02-01 | 433 |
| 2009: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-02-01 | 545 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-02-01 | 394 |
| Number of retired or separated participants receiving benefits | 2009-02-01 | 17 |
| Number of other retired or separated participants entitled to future benefits | 2009-02-01 | 0 |
| Total of all active and inactive participants | 2009-02-01 | 411 |
| Total participants | 2009-02-01 | 0 |
| 2022: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | Yes |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-02-01 | Type of plan entity | Single employer plan |
| 2014-02-01 | Submission has been amended | No |
| 2014-02-01 | This submission is the final filing | No |
| 2014-02-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2014-02-01 | Plan is a collectively bargained plan | No |
| 2014-02-01 | Plan funding arrangement – Insurance | Yes |
| 2014-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-02-01 | Type of plan entity | Single employer plan |
| 2013-02-01 | Submission has been amended | No |
| 2013-02-01 | This submission is the final filing | No |
| 2013-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-02-01 | Plan is a collectively bargained plan | No |
| 2013-02-01 | Plan funding arrangement – Insurance | Yes |
| 2013-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-02-01 | Type of plan entity | Single employer plan |
| 2012-02-01 | Submission has been amended | No |
| 2012-02-01 | This submission is the final filing | No |
| 2012-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-02-01 | Plan is a collectively bargained plan | No |
| 2012-02-01 | Plan funding arrangement – Insurance | Yes |
| 2012-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-02-01 | Type of plan entity | Single employer plan |
| 2011-02-01 | Submission has been amended | No |
| 2011-02-01 | This submission is the final filing | No |
| 2011-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-02-01 | Plan is a collectively bargained plan | No |
| 2011-02-01 | Plan funding arrangement – Insurance | Yes |
| 2011-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: INDIANA MILLS & MANUFACTURING, INC. WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-02-01 | Type of plan entity | Single employer plan |
| 2009-02-01 | First time form 5500 has been submitted | Yes |
| 2009-02-01 | Submission has been amended | No |
| 2009-02-01 | This submission is the final filing | No |
| 2009-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-02-01 | Plan is a collectively bargained plan | No |
| 2009-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 166078 |
| Policy instance | 4 |
| Insurance contract or identification number | 166078 | | Number of Individuals Covered | 533 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $74,505 | | Total amount of fees paid to insurance company | USD $13,296 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $59,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40,531 | | Amount paid for insurance broker fees | 2125 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | OTP01246-22 |
| Policy instance | 3 |
| Insurance contract or identification number | OTP01246-22 | | Number of Individuals Covered | 446 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,658 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $67,945 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,658 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12137340 |
| Policy instance | 2 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 468 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,394 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $67,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,575 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 ) |
| Policy contract number | 913191110IN |
| Policy instance | 1 |
| Insurance contract or identification number | 913191110IN | | Number of Individuals Covered | 907 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $256,883 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 ) |
| Policy contract number | 913191110IN |
| Policy instance | 1 |
| Insurance contract or identification number | 913191110IN | | Number of Individuals Covered | 877 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $257,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12137340 |
| Policy instance | 2 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 430 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,115 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,216 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,346 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | 417004413179 |
| Policy instance | 3 |
| Insurance contract or identification number | 417004413179 | | Number of Individuals Covered | 570 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $84,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 166078 |
| Policy instance | 4 |
| Insurance contract or identification number | 166078 | | Number of Individuals Covered | 570 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $83,895 | | Total amount of fees paid to insurance company | USD $19,924 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $94,421 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $83,895 | | Amount paid for insurance broker fees | 11859 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 ) |
| Policy contract number | 913191110IN |
| Policy instance | 1 |
| Insurance contract or identification number | 913191110IN | | Number of Individuals Covered | 911 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $256,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12137340 |
| Policy instance | 2 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 450 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,213 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,213 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 166078 |
| Policy instance | 4 |
| Insurance contract or identification number | 166078 | | Number of Individuals Covered | 909 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $82,737 | | Total amount of fees paid to insurance company | USD $23,265 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $41,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $82,737 | | Amount paid for insurance broker fees | 13691 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCCLOT40506 |
| Policy instance | 3 |
| Insurance contract or identification number | HCCLOT40506 | | Number of Individuals Covered | 436 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $8,242 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $82,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,242 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCCLOT40506 |
| Policy instance | 4 |
| Insurance contract or identification number | HCCLOT40506 | | Number of Individuals Covered | 444 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $8,978 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $89,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,978 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016909-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 01-016909-00 | | Number of Individuals Covered | 605 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $39,110 | | Total amount of fees paid to insurance company | USD $5,669 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $229,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,110 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 5669 | | Additional information about fees paid to insurance broker | GROUP SUPPLEMENTAL COMMISSIONS |
|
| DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
| Policy contract number | 812 |
| Policy instance | 1 |
| Insurance contract or identification number | 812 | | Number of Individuals Covered | 894 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,353 | | 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 $0 | | Amount paid for insurance broker fees | 1353 | | Additional information about fees paid to insurance broker | NEW BUSINESS BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12137340 |
| Policy instance | 3 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 446 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,182 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $69,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,182 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 166078 |
| Policy instance | 4 |
| Insurance contract or identification number | 166078 | | Number of Individuals Covered | 608 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $16,229 | | Total amount of fees paid to insurance company | USD $16,531 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,229 | | Amount paid for insurance broker fees | 13691 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 166078 |
| Policy instance | 5 |
| Insurance contract or identification number | 166078 | | Number of Individuals Covered | 608 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $16,229 | | Total amount of fees paid to insurance company | USD $16,531 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,229 | | Amount paid for insurance broker fees | 13691 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 13137340 |
| Policy instance | 3 |
| Insurance contract or identification number | 13137340 | | Number of Individuals Covered | 485 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,344 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,756 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016909-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 01-016909-00 | | Number of Individuals Covered | 660 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $51,972 | | Total amount of fees paid to insurance company | USD $10,930 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $387,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,800 | | Amount paid for insurance broker fees | 10930 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
| Policy contract number | 812 |
| Policy instance | 1 |
| Insurance contract or identification number | 812 | | Number of Individuals Covered | 950 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 12137340 |
| Policy instance | 3 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 411 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,800 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,800 | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER HEALTH AND BENEFITS INC. |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016909-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 01-016909-00 | | Number of Individuals Covered | 461 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $45,366 | | Total amount of fees paid to insurance company | USD $7,738 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $272,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,366 | | Amount paid for insurance broker fees | 7738 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER HEALTH AND BENEFITS INC. |
|
| DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
| Policy contract number | 0000812 |
| Policy instance | 1 |
| Insurance contract or identification number | 0000812 | | Number of Individuals Covered | 871 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $3,690 | | 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 $3,690 | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER HEALTH AND BENEFITS, INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00465331 |
| Policy instance | 1 |
| Insurance contract or identification number | 00465331 | | Number of Individuals Covered | 442 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $45,041 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $300,272 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,041 | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER HEALTH AND BENEFITS INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 12137340 |
| Policy instance | 2 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 406 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,801 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,801 | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER HEALTH AND BENEFITS INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00465331 |
| Policy instance | 1 |
| Insurance contract or identification number | 00465331 | | Number of Individuals Covered | 459 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $41,528 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $276,852 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,528 | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER BENEFITS INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
| Policy contract number | 12137340 |
| Policy instance | 2 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 422 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,688 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,688 | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER BENEFITS INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
| Policy contract number | 12137340 |
| Policy instance | 2 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 462 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $3,159 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,159 | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER BENEFITS INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00465331 |
| Policy instance | 1 |
| Insurance contract or identification number | 00465331 | | Number of Individuals Covered | 488 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $43,790 | | Total amount of fees paid to insurance company | USD $6,841 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $294,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,790 | | Amount paid for insurance broker fees | 6841 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER BENEFITS INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00465331 |
| Policy instance | 1 |
| Insurance contract or identification number | 00465331 | | Number of Individuals Covered | 537 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $33,476 | | Total amount of fees paid to insurance company | USD $893 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $245,726 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,476 | | Amount paid for insurance broker fees | 893 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER BENEFITS INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
| Policy contract number | 12137340 |
| Policy instance | 2 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 428 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $2,899 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,899 | | Insurance broker organization code? | 3 | | Insurance broker name | CONNER BENEFITS INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX963872 |
| Policy instance | 3 |
| Insurance contract or identification number | FLX963872 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $2,774 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,491 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
| Policy contract number | 12137340 |
| Policy instance | 7 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 393 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $2,472 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $49,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750656 |
| Policy instance | 6 |
| Insurance contract or identification number | LK 750656 | | Number of Individuals Covered | 378 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $9,108 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $91,082 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 965503 |
| Policy instance | 4 |
| Insurance contract or identification number | OK 965503 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $502 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,347 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX962789 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX962789 | | Number of Individuals Covered | 429 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $4,528 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 964424 |
| Policy instance | 1 |
| Insurance contract or identification number | OK 964424 | | Number of Individuals Covered | 429 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $722 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 962045 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 962045 | | Number of Individuals Covered | 429 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $6,271 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK964424 |
| Policy instance | 1 |
| Insurance contract or identification number | OK964424 | | Number of Individuals Covered | 422 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $780 | | Total amount of fees paid to insurance company | USD $152 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK962045 |
| Policy instance | 2 |
| Insurance contract or identification number | LK962045 | | Number of Individuals Covered | 422 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $6,913 | | Total amount of fees paid to insurance company | USD $1,407 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $57,606 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK750656 |
| Policy instance | 4 |
| Insurance contract or identification number | LK750656 | | Number of Individuals Covered | 383 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $10,621 | | Total amount of fees paid to insurance company | USD $2,670 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $106,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 ) |
| Policy contract number | 12137340 |
| Policy instance | 5 |
| Insurance contract or identification number | 12137340 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $2,563 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX962789 |
| Policy instance | 3 |
| Insurance contract or identification number | FLX962789 | | Number of Individuals Covered | 422 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $5,008 | | Total amount of fees paid to insurance company | USD $1,267 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
