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THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 401k Plan overview

Plan NameTHE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM
Plan identification number 501

THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision

401k Sponsoring company profile

THE GOOD SAMARITAN HOME, INC. has sponsored the creation of one or more 401k plans.

Company Name:THE GOOD SAMARITAN HOME, INC.
Employer identification number (EIN):351065494
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about THE GOOD SAMARITAN HOME, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations
Incorporation Date: 1988-08-03
Company Identification Number: N27722
Legal Registered Office Address: 13580 S.W. 252 STREET

HOMESTEAD

33032

More information about THE GOOD SAMARITAN HOME, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01RAY MURINNON2023-04-03
5012021-01-01CHRISTA BENNETT2022-06-01
5012020-01-01CHRISTA BENNETT2021-09-16 CHRISTA BENNETT2021-09-16
5012018-01-01SHARON FOSTER2019-10-10 JESSICA WEST2019-10-10
5012017-01-01
5012016-01-01
5012015-01-01
5012015-01-01SHARON FOSTER2016-07-29
5012014-01-01
5012013-01-01
5012012-05-01BETSY PUTHOFF
5012011-05-01BETSY PUTHOFF
5012010-05-01BETSY PUTHOFF
5012009-05-01BETSY PUTHOFF BETSY PUTHOFF2010-09-27
5012009-05-01BETSY PUTHOFF

Plan Statistics for THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM

401k plan membership statisitcs for THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM

Measure Date Value
2022: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2022 401k membership
Total participants, beginning-of-year2022-01-01116
Total number of active participants reported on line 7a of the Form 55002022-01-01136
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01136
2021: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2021 401k membership
Total participants, beginning-of-year2021-01-01215
Total number of active participants reported on line 7a of the Form 55002021-01-01113
Number of retired or separated participants receiving benefits2021-01-013
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01116
2020: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2020 401k membership
Total participants, beginning-of-year2020-01-01209
Total number of active participants reported on line 7a of the Form 55002020-01-01215
Total of all active and inactive participants2020-01-01215
2018: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2018 401k membership
Total participants, beginning-of-year2018-01-01198
Total number of active participants reported on line 7a of the Form 55002018-01-01209
Total of all active and inactive participants2018-01-01209
2017: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2017 401k membership
Total participants, beginning-of-year2017-01-01199
Total number of active participants reported on line 7a of the Form 55002017-01-01198
Total of all active and inactive participants2017-01-01198
2016: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2016 401k membership
Total participants, beginning-of-year2016-01-01173
Total number of active participants reported on line 7a of the Form 55002016-01-01199
Total of all active and inactive participants2016-01-01199
2015: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2015 401k membership
Total participants, beginning-of-year2015-01-01177
Total number of active participants reported on line 7a of the Form 55002015-01-01173
Total of all active and inactive participants2015-01-01173
2014: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2014 401k membership
Total participants, beginning-of-year2014-01-01152
Total number of active participants reported on line 7a of the Form 55002014-01-01177
Total of all active and inactive participants2014-01-01177
2013: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2013 401k membership
Total participants, beginning-of-year2013-01-01194
Total number of active participants reported on line 7a of the Form 55002013-01-01152
Number of retired or separated participants receiving benefits2013-01-010
Total of all active and inactive participants2013-01-01152
2012: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2012 401k membership
Total participants, beginning-of-year2012-05-01186
Total number of active participants reported on line 7a of the Form 55002012-05-01193
Number of retired or separated participants receiving benefits2012-05-011
Total of all active and inactive participants2012-05-01194
Total participants2012-05-01194
2011: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2011 401k membership
Total participants, beginning-of-year2011-05-01197
Total number of active participants reported on line 7a of the Form 55002011-05-01185
Number of retired or separated participants receiving benefits2011-05-011
Total of all active and inactive participants2011-05-01186
Total participants2011-05-01186
2010: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2010 401k membership
Total participants, beginning-of-year2010-05-01162
Total number of active participants reported on line 7a of the Form 55002010-05-01161
Number of retired or separated participants receiving benefits2010-05-011
Total of all active and inactive participants2010-05-01162
2009: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2009 401k membership
Total participants, beginning-of-year2009-05-01171
Total number of active participants reported on line 7a of the Form 55002009-05-01163
Number of retired or separated participants receiving benefits2009-05-012
Number of other retired or separated participants entitled to future benefits2009-05-010
Total of all active and inactive participants2009-05-01165

Form 5500 Responses for THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM

2022: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2018: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01This return/report is a short plan year return/report (less than 12 months)Yes
2012-05-01Plan funding arrangement – InsuranceYes
2012-05-01Plan benefit arrangement – InsuranceYes
2011: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01First time form 5500 has been submittedYes
2011-05-01Plan funding arrangement – InsuranceYes
2011-05-01Plan benefit arrangement – InsuranceYes
2010: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2010 form 5500 responses
2010-05-01Type of plan entitySingle employer plan
2010-05-01Submission has been amendedYes
2010-05-01This submission is the final filingYes
2010-05-01Plan funding arrangement – InsuranceYes
2010-05-01Plan benefit arrangement – InsuranceYes
2009: THE GOOD SAMARITAN HOME, INC. SECTION 125 PREMIUM 2009 form 5500 responses
2009-05-01Type of plan entitySingle employer plan
2009-05-01Submission has been amendedNo
2009-05-01This submission is the final filingNo
2009-05-01This return/report is a short plan year return/report (less than 12 months)No
2009-05-01Plan is a collectively bargained planNo
2009-05-01Plan funding arrangement – InsuranceYes
2009-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVARIOUS
Policy instance 4
Insurance contract or identification numberVARIOUS
Number of Individuals Covered136
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $12,448
Total amount of fees paid to insurance companyUSD $5,847
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D AND VOLUNTARY BENEFITS AND WORKSITE BENEFITS
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 CarrierUSD $109,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,448
Amount paid for insurance broker fees380
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12141123
Policy instance 3
Insurance contract or identification number12141123
Number of Individuals Covered99
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $9,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number412003413283
Policy instance 2
Insurance contract or identification number412003413283
Number of Individuals Covered80
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedTRANSPLANT
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 CarrierUSD $5,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )
Policy contract number417002413283
Policy instance 1
Insurance contract or identification number417002413283
Number of Individuals Covered80
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,694
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $169,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,694
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number412003413283
Policy instance 2
Insurance contract or identification number412003413283
Number of Individuals Covered80
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedTRANSPLANT
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 CarrierUSD $5,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )
Policy contract number417002413283
Policy instance 1
Insurance contract or identification number417002413283
Number of Individuals Covered80
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $118,602
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 number12141123
Policy instance 3
Insurance contract or identification number12141123
Number of Individuals Covered90
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $9,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVARIOUS
Policy instance 4
Insurance contract or identification numberVARIOUS
Number of Individuals Covered132
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $14,416
Total amount of fees paid to insurance companyUSD $1,868
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D AND VOLUNTARY BENEFITS AND WORKSITE BENEFITS
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 CarrierUSD $162,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,722
Insurance broker organization code?3
Amount paid for insurance broker fees1868
Additional information about fees paid to insurance brokerFEES
HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )
Policy contract number805101943511
Policy instance 2
Insurance contract or identification number805101943511
Number of Individuals Covered215
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )
Policy contract number417002413283
Policy instance 3
Insurance contract or identification number417002413283
Number of Individuals Covered90
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $151,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number417003413283
Policy instance 4
Insurance contract or identification number417003413283
Number of Individuals Covered90
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedTRANSPLANT
Welfare Benefit Premiums Paid to CarrierUSD $7,452
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 number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered126
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,946
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 number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered148
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,999
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 number805101943511
Policy instance 2
Insurance contract or identification number805101943511
Number of Individuals Covered209
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )
Policy contract number00248479
Policy instance 3
Insurance contract or identification number00248479
Number of Individuals Covered139
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $311,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )
Policy contract number00248479
Policy instance 3
Insurance contract or identification number00248479
Number of Individuals Covered183
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $250,597
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 number805101943511
Policy instance 2
Insurance contract or identification number805101943511
Number of Individuals Covered198
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,235
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 number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered163
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL30760
Policy instance 3
Insurance contract or identification numberHCL30760
Number of Individuals Covered138
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $206,901
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 number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered147
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,255
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 number805101943511
Policy instance 2
Insurance contract or identification number805101943511
Number of Individuals Covered173
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,485
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 number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered137
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,197
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 number805101943511
Policy instance 2
Insurance contract or identification number805101943511
Number of Individuals Covered177
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL30760
Policy instance 3
Insurance contract or identification numberHCL30760
Number of Individuals Covered134
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $215,736
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 number805101943511
Policy instance 2
Insurance contract or identification number805101943511
Number of Individuals Covered146
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameINSURING RESOURCES, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52050 )
Policy contract number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered150
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )
Policy contract numberELSL-1022
Policy instance 3
Insurance contract or identification numberELSL-1022
Number of Individuals Covered152
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $201,272
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 number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered165
Insurance policy start date2012-05-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WELBORN HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 12540 )
Policy contract numberW9365
Policy instance 2
Insurance contract or identification numberW9365
Number of Individuals Covered238
Insurance policy start date2012-05-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $472,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberMG18355
Policy instance 3
Insurance contract or identification numberMG18355
Number of Individuals Covered193
Insurance policy start date2012-05-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $4,712
Total amount of fees paid to insurance companyUSD $169
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $80,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,712
Amount paid for insurance broker fees169
Insurance broker organization code?3
Insurance broker nameINSURING RESOURCES, LLC
HEALTH RESOURCES INC (National Association of Insurance Commissioners NAIC id number: 96687 )
Policy contract number805101943511
Policy instance 4
Insurance contract or identification number805101943511
Number of Individuals Covered153
Insurance policy start date2012-05-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $38,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameINSURING RESOURCES, LLC
GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )
Policy contract numberELSL-1022
Policy instance 5
Insurance contract or identification numberELSL-1022
Number of Individuals Covered162
Insurance policy start date2012-05-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $172,702
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 number805101943511
Policy instance 4
Insurance contract or identification number805101943511
Number of Individuals Covered155
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $64,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberMG18355
Policy instance 3
Insurance contract or identification numberMG18355
Number of Individuals Covered203
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $6,460
Total amount of fees paid to insurance companyUSD $214
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $123,112
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 number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered169
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WELBORN HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 12540 )
Policy contract numberW9365
Policy instance 2
Insurance contract or identification numberW9365
Number of Individuals Covered236
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $6,521
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,308,240
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 number12141123
Policy instance 2
Insurance contract or identification number12141123
Number of Individuals Covered163
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WELBORN HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 12540 )
Policy contract numberW9365
Policy instance 3
Insurance contract or identification numberW9365
Number of Individuals Covered162
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $7,254
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,194,857
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 number12141123
Policy instance 1
Insurance contract or identification number12141123
Number of Individuals Covered167
Insurance policy start date2010-03-01
Insurance policy end date2010-04-30
Total amount of commissions paid to insurance brokerUSD $242
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,413
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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