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FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameFIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN
Plan identification number 503

FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

FIDELITY LIFE ASSOCIATION has sponsored the creation of one or more 401k plans.

Company Name:FIDELITY LIFE ASSOCIATION
Employer identification number (EIN):361068685
NAIC Classification:524140

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032022-01-01
5032021-01-01DANNIELLE SMALLWOOD2022-04-06
5032020-01-01JOELLE STRZELECKI2021-08-27
5032019-01-01JOELLE STRZELECKI2020-09-16
5032019-01-01JOELLE STRZELECKI2021-08-27
5032018-01-01
5032018-01-01JOELLE STRZELECKI2020-09-16
5032018-01-01JOELLE STRZELECKI2021-08-27
5032017-01-01
5032016-01-01SANDRA ENSHIWAT

Plan Statistics for FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN

401k plan membership statisitcs for FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN

Measure Date Value
2022: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01469
Total number of active participants reported on line 7a of the Form 55002022-01-01425
Number of retired or separated participants receiving benefits2022-01-018
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01433
2021: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01402
Total number of active participants reported on line 7a of the Form 55002021-01-01457
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01457
Number of employers contributing to the scheme2021-01-010
2020: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01418
Total number of active participants reported on line 7a of the Form 55002020-01-01402
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01402
Number of employers contributing to the scheme2020-01-010
2019: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01408
Total number of active participants reported on line 7a of the Form 55002019-01-01418
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01418
Number of employers contributing to the scheme2019-01-010
2018: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01120
Total number of active participants reported on line 7a of the Form 55002018-01-01371
Number of retired or separated participants receiving benefits2018-01-012
Number of other retired or separated participants entitled to future benefits2018-01-0135
Total of all active and inactive participants2018-01-01408
Number of employers contributing to the scheme2018-01-010
2017: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01103
Total number of active participants reported on line 7a of the Form 55002017-01-01120
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01120
2016: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01101
Total number of active participants reported on line 7a of the Form 55002016-01-01100
Number of retired or separated participants receiving benefits2016-01-013
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01103

Form 5500 Responses for FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN

2022: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 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: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
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: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedYes
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 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: FIDELITY LIFE ASSOCIATION HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01First time form 5500 has been submittedYes
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )
Policy contract number12265407
Policy instance 5
Insurance contract or identification number12265407
Number of Individuals Covered414
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,026
Total amount of fees paid to insurance companyUSD $0
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 $62,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,026
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNA
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20467
Policy instance 4
Insurance contract or identification number20467
Number of Individuals Covered333
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $12,946
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
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 $262,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,946
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNA
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0722694
Policy instance 3
Insurance contract or identification numberR0722694
Number of Individuals Covered238
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $10,035
Total amount of fees paid to insurance companyUSD $808
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 providedCRITICAL ILLNESS, ACCIDENT, HOSPITAL
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 $34,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,035
Amount paid for insurance broker fees808
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908139
Policy instance 2
Insurance contract or identification number908139
Number of Individuals Covered193
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $7,587
Total amount of fees paid to insurance companyUSD $1,099
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $50,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,587
Amount paid for insurance broker fees1099
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number127094
Policy instance 1
Insurance contract or identification number127094
Number of Individuals Covered392
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,209
Total amount of fees paid to insurance companyUSD $2,950
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $165,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,209
Amount paid for insurance broker fees2950
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20467
Policy instance 1
Insurance contract or identification number20467
Number of Individuals Covered365
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $11,611
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $285,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $11,611
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )
Policy contract number12265407
Policy instance 2
Insurance contract or identification number12265407
Number of Individuals Covered448
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,093
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $62,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,093
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number127094
Policy instance 3
Insurance contract or identification number127094
Number of Individuals Covered457
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $24,305
Total amount of fees paid to insurance companyUSD $2,029
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $238,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,305
Amount paid for insurance broker fees2029
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number127094
Policy instance 3
Insurance contract or identification number127094
Number of Individuals Covered402
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $30,802
Total amount of fees paid to insurance companyUSD $3,380
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $346,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,802
Amount paid for insurance broker fees3380
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )
Policy contract number12265407
Policy instance 2
Insurance contract or identification number12265407
Number of Individuals Covered398
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,337
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,337
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1105345
Policy instance 1
Insurance contract or identification number1105345
Number of Individuals Covered581
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $12,647
Total amount of fees paid to insurance companyUSD $6,570
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $216,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,647
Amount paid for insurance broker fees6570
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1105345
Policy instance 1
Insurance contract or identification number1105345
Number of Individuals Covered592
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $11,250
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $251,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,250
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )
Policy contract number12265407
Policy instance 2
Insurance contract or identification number12265407
Number of Individuals Covered399
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,596
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $55,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,596
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number790910
Policy instance 3
Insurance contract or identification number790910
Number of Individuals Covered529
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $130,135
Total amount of fees paid to insurance companyUSD $2,981
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,018,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $130,135
Amount paid for insurance broker fees2981
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS NON-MONETARY COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number127094
Policy instance 4
Insurance contract or identification number127094
Number of Individuals Covered418
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $23,177
Total amount of fees paid to insurance companyUSD $2,322
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $307,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,177
Amount paid for insurance broker fees2322
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number127094
Policy instance 6
Insurance contract or identification number127094
Number of Individuals Covered368
Insurance policy start date2018-09-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,042
Total amount of fees paid to insurance companyUSD $351
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $68,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,042
Amount paid for insurance broker fees351
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05913870
Policy instance 1
Insurance contract or identification numberKM05913870
Number of Individuals Covered496
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $18,355
Total amount of fees paid to insurance companyUSD $4,336
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $275,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,355
Amount paid for insurance broker fees4336
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )
Policy contract number12265407
Policy instance 2
Insurance contract or identification number12265407
Number of Individuals Covered382
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,031
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $49,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,031
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number790910
Policy instance 3
Insurance contract or identification number790910
Number of Individuals Covered512
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $96,709
Total amount of fees paid to insurance companyUSD $1,545
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,825,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $96,709
Amount paid for insurance broker fees1545
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number127094
Policy instance 4
Insurance contract or identification number127094
Number of Individuals Covered371
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $14,291
Total amount of fees paid to insurance companyUSD $1,846
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $181,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,291
Amount paid for insurance broker fees1846
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number127094
Policy instance 5
Insurance contract or identification number127094
Number of Individuals Covered368
Insurance policy start date2018-09-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,042
Total amount of fees paid to insurance companyUSD $351
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $68,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,042
Amount paid for insurance broker fees351
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0722694
Policy instance 4
Insurance contract or identification numberR0722694
Number of Individuals Covered108
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $6,855
Total amount of fees paid to insurance companyUSD $656
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $10,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,855
Amount paid for insurance broker fees656
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number127094
Policy instance 4
Insurance contract or identification number127094
Number of Individuals Covered120
Insurance policy start date2016-09-01
Insurance policy end date2017-08-31
Total amount of commissions paid to insurance brokerUSD $11,974
Total amount of fees paid to insurance companyUSD $2,453
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $140,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,974
Amount paid for insurance broker fees2453
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberB90910
Policy instance 3
Insurance contract or identification numberB90910
Number of Individuals Covered246
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $57,753
Total amount of fees paid to insurance companyUSD $2,425
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,465,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $57,753
Amount paid for insurance broker fees2425
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 )
Policy contract number12265407
Policy instance 2
Insurance contract or identification number12265407
Number of Individuals Covered121
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,158
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,158
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05913870
Policy instance 1
Insurance contract or identification numberKM05913870
Number of Individuals Covered410
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $8,757
Total amount of fees paid to insurance companyUSD $1,928
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $136,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,757
Amount paid for insurance broker fees1928
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC

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