MIDWEST COMMUNITY BANK has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 240 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 0 |
| 2021: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 248 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 240 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 240 |
| 2020: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 179 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 248 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 248 |
| 2019: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 155 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 179 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 179 |
| 2018: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 153 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 155 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 155 |
| 2017: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 153 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 153 |
| 2016: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 130 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 137 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 137 |
| 2015: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 130 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 130 |
| 2014: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 99 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 105 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 105 |
| 2022: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | This submission is the final filing | Yes |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: MIDWEST COMMUNITY BANK WELFARE BENEFIT PLAN 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 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 6 |
| Insurance contract or identification number | B80669 P81738 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2022-04-15 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $18,354 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $428,581 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,354 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908402 |
| Policy instance | 5 |
| Insurance contract or identification number | 908402 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $1,324 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,681 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,324 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $8,388 | | Total amount of fees paid to insurance company | USD $1,104 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $69,530 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,388 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1104 | | Additional information about fees paid to insurance broker | BONUSES AND ADDITIONAL PAYMENTS |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2021-04-15 | | Insurance policy end date | 2022-04-14 | | Total amount of commissions paid to insurance broker | USD $65,719 | | Total amount of fees paid to insurance company | USD $4,250 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,673,694 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65,719 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 4250 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 4 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $1,148 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | A&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,148 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908402 |
| Policy instance | 3 |
| Insurance contract or identification number | 908402 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $7,289 | | Total amount of fees paid to insurance company | USD $2,535 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $138,616 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,652 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2535 | | Additional information about fees paid to insurance broker | BONUSES AND ADDITIONAL PAYMENTS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908402 |
| Policy instance | 3 |
| Insurance contract or identification number | 908402 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $4,350 | | Total amount of fees paid to insurance company | USD $1,479 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $119,624 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,350 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1479 | | Additional information about fees paid to insurance broker | BONUSES AND ADDITIONAL PAYMENTS |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Number of Individuals Covered | 310 | | Insurance policy start date | 2020-04-15 | | Insurance policy end date | 2021-04-14 | | Total amount of commissions paid to insurance broker | USD $61,882 | | Total amount of fees paid to insurance company | USD $3,450 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,487,117 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,882 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3450 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $6,019 | | Total amount of fees paid to insurance company | USD $827 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $54,772 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,019 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 827 | | Additional information about fees paid to insurance broker | BONUSES AND ADDITIONAL PAYMENTS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908402 |
| Policy instance | 3 |
| Insurance contract or identification number | 908402 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $4,705 | | Total amount of fees paid to insurance company | USD $2,813 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,705 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2813 | | Additional information about fees paid to insurance broker | BONUSES AND ADDITIONAL PAYMENTS |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2019-04-15 | | Insurance policy end date | 2020-04-14 | | Total amount of commissions paid to insurance broker | USD $43,326 | | Total amount of fees paid to insurance company | USD $2,275 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $948,711 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,326 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2275 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $5,849 | | Total amount of fees paid to insurance company | USD $843 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $40,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,849 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 843 | | Additional information about fees paid to insurance broker | BONUSES AND ADDITIONAL PAYMENTS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908402 |
| Policy instance | 3 |
| Insurance contract or identification number | 908402 | | Number of Individuals Covered | 84 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $3,496 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,496 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2018-04-15 | | Insurance policy end date | 2019-04-14 | | Total amount of commissions paid to insurance broker | USD $37,091 | | Total amount of fees paid to insurance company | USD $2,025 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $846,001 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,960 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2025 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $4,130 | | Total amount of fees paid to insurance company | USD $440 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $30,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,130 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 440 | | Additional information about fees paid to insurance broker | BONUSES AND ADDITIONAL PAYMENTS |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2017-04-15 | | Insurance policy end date | 2018-04-14 | | Total amount of commissions paid to insurance broker | USD $32,171 | | Total amount of fees paid to insurance company | USD $1,825 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $739,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,171 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1825 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $3,134 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $23,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,025 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2016-05-01 | | Insurance policy end date | 2017-04-30 | | Total amount of commissions paid to insurance broker | USD $2,791 | | Total amount of fees paid to insurance company | USD $32 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $20,312 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,791 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 32 | | Additional information about fees paid to insurance broker | BONUS AND ADDITIONAL PAYMENTS |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Insurance policy start date | 2016-04-15 | | Insurance policy end date | 2017-04-15 | | Total amount of commissions paid to insurance broker | USD $29,512 | | Total amount of fees paid to insurance company | USD $1,675 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $586,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,512 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1675 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $2,359 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $18,453 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,359 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Insurance policy start date | 2015-04-15 | | Insurance policy end date | 2016-04-15 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Insurance policy start date | 2014-04-15 | | Insurance policy end date | 2015-04-15 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $2,411 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $16,010 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,411 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B80669 P81738 |
| Policy instance | 2 |
| Insurance contract or identification number | B80669 P81738 | | Insurance policy start date | 2013-04-15 | | Insurance policy end date | 2014-04-15 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220514 |
| Policy instance | 1 |
| Insurance contract or identification number | 220514 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,782 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,782 | | Insurance broker organization code? | 3 |
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