LAFAYETTE VENETIAN BLIND, INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL
401k plan membership statisitcs for LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL
| Measure | Date | Value |
|---|
| 2017: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 403 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 395 |
| Total of all active and inactive participants | 2017-01-01 | 395 |
| Total participants | 2017-01-01 | 395 |
| 2016: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 417 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 403 |
| Total of all active and inactive participants | 2016-01-01 | 403 |
| Total participants | 2016-01-01 | 403 |
| 2015: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 434 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 417 |
| Total of all active and inactive participants | 2015-01-01 | 417 |
| Total participants | 2015-01-01 | 417 |
| 2014: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 489 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 434 |
| Total of all active and inactive participants | 2014-01-01 | 434 |
| Total participants | 2014-01-01 | 434 |
| 2013: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 508 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 489 |
| Total of all active and inactive participants | 2013-05-01 | 489 |
| Total participants | 2013-05-01 | 489 |
| 2012: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 531 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 508 |
| Total of all active and inactive participants | 2012-05-01 | 508 |
| Total participants | 2012-05-01 | 508 |
| 2009: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-05-01 | 687 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-05-01 | 632 |
| Number of retired or separated participants receiving benefits | 2009-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-05-01 | 0 |
| Total of all active and inactive participants | 2009-05-01 | 632 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-05-01 | 0 |
| Total participants | 2009-05-01 | 632 |
| 2017: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | First time form 5500 has been submitted | Yes |
| 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 benefit arrangement – Insurance | Yes |
| 2016: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | First time form 5500 has been submitted | Yes |
| 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 benefit arrangement – Insurance | Yes |
| 2015: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | First time form 5500 has been submitted | Yes |
| 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 benefit arrangement – Insurance | Yes |
| 2014: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | First time form 5500 has been submitted | Yes |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Submission has been amended | No |
| 2013-05-01 | This submission is the final filing | No |
| 2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2013-05-01 | Plan is a collectively bargained plan | No |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | First time form 5500 has been submitted | Yes |
| 2012-05-01 | Submission has been amended | No |
| 2012-05-01 | This submission is the final filing | No |
| 2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-05-01 | Plan is a collectively bargained plan | No |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: LAFAYETTE VENETIAN BLIND SHORT/LONG TERM DISABILITY & LIFE INS PL 2009 form 5500 responses |
|---|
| 2009-05-01 | Type of plan entity | Single employer plan |
| 2009-05-01 | First time form 5500 has been submitted | Yes |
| 2009-05-01 | Submission has been amended | No |
| 2009-05-01 | This submission is the final filing | No |
| 2009-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-05-01 | Plan is a collectively bargained plan | No |
| 2009-05-01 | Plan funding arrangement – Insurance | Yes |
| 2009-05-01 | Plan benefit arrangement – Insurance | Yes |
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016534-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016534-00 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $35,661 | | Total amount of fees paid to insurance company | USD $6,951 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $237,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,661 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 6952 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker name | MJ INSURANCE INC. |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016534-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016534-00 | | Number of Individuals Covered | 403 | | Insurance policy start date | 2016-01-01 | | Insurance policy end date | 2016-12-31 | | Total amount of commissions paid to insurance broker | USD $34,838 | | Total amount of fees paid to insurance company | USD $7,319 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $241,553 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,838 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 7319 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker name | MJ INSURANCE INC |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016534-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016534-00 | | Number of Individuals Covered | 417 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $44,325 | | Total amount of fees paid to insurance company | USD $7,534 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $251,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,798 | | Amount paid for insurance broker fees | 7534 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016534-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016534-00 | | Number of Individuals Covered | 434 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $31,246 | | Total amount of fees paid to insurance company | USD $5,722 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $252,417 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,246 | | Amount paid for insurance broker fees | 5722 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC |
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| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F071458 |
| Policy instance | 3 |
| Insurance contract or identification number | F071458 | | Number of Individuals Covered | 984 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $13,538 | | Total amount of fees paid to insurance company | USD $102 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $78,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,538 | | Amount paid for insurance broker fees | 102 | | Insurance broker name | MJ INSURANCE INC |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 962399 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 962399 | | Number of Individuals Covered | 489 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $6,186 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $41,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,186 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | MJ INSURANCE INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK750794 |
| Policy instance | 1 |
| Insurance contract or identification number | LK750794 | | Number of Individuals Covered | 489 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,699 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $51,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,699 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | MJ INSURANCE INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750794 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 750794 | | Number of Individuals Covered | 508 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-05-01 | | Total amount of commissions paid to insurance broker | USD $13,447 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,295 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,331 | | Insurance broker name | MJ INSURANCE, INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 962399 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 962399 | | Number of Individuals Covered | 508 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-05-01 | | Total amount of commissions paid to insurance broker | USD $11,561 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $61,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,816 | | Insurance broker name | MJ INSURANCE INC |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017458 |
| Policy instance | 4 |
| Insurance contract or identification number | F017458 | | Number of Individuals Covered | 1039 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $19,744 | | Total amount of fees paid to insurance company | USD $4,743 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $116,142 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,534 | | Amount paid for insurance broker fees | 4684 | | Insurance broker name | MJ INSURANCE INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SDJ960212 |
| Policy instance | 3 |
| Insurance contract or identification number | SDJ960212 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-05-01 | | Total amount of commissions paid to insurance broker | USD $98 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | STATUTORY DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $523 | | 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 | | Insurance broker name | MJ INSURANCE INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK750794 |
| Policy instance | 1 |
| Insurance contract or identification number | LK750794 | | Number of Individuals Covered | 549 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-05-01 | | Total amount of commissions paid to insurance broker | USD $11,256 | | Total amount of fees paid to insurance company | USD $1,673 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $75,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $11,256 | | Amount paid for insurance broker fees | 1673 | | Insurance broker name | APEX BENEFITS GROUP INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK962399 |
| Policy instance | 2 |
| Insurance contract or identification number | LK962399 | | Number of Individuals Covered | 549 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-05-01 | | Total amount of commissions paid to insurance broker | USD $9,940 | | Total amount of fees paid to insurance company | USD $1,480 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,268 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $9,940 | | Amount paid for insurance broker fees | 1480 | | Insurance broker name | APEX BENEFITS GROUP INC |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017458 |
| Policy instance | 3 |
| Insurance contract or identification number | F017458 | | Number of Individuals Covered | 1099 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $21,182 | | Total amount of fees paid to insurance company | USD $209 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $125,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,182 | | Amount paid for insurance broker fees | 209 | | Insurance broker name | APEX BENEFITS GROUP |
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