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KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NameKELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN
Plan identification number 501

KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT 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

KELLY, SCOTT AND MADISON, INC. has sponsored the creation of one or more 401k plans.

Company Name:KELLY, SCOTT AND MADISON, INC.
Employer identification number (EIN):362586788
NAIC Classification:541800

Additional information about KELLY, SCOTT AND MADISON, INC.

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 0769723

More information about KELLY, SCOTT AND MADISON, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01DAVID WARSO2023-03-23
5012021-01-01DAVID WARSO2022-05-10
5012020-01-01DAVID WARSO2021-05-24
5012019-01-01DAVID WARSO2020-07-06
5012018-01-01
5012017-01-01
5012016-01-01DONALD CARTER DONALD CARTER2017-10-12
5012015-01-01DONALD D CARTER
5012014-01-01DARLENE SERRANO
5012013-02-01DARLENE SERRANO
5012012-02-01DARLENE SERRANO

Plan Statistics for KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01130
Total number of active participants reported on line 7a of the Form 55002022-01-01167
Number of retired or separated participants receiving benefits2022-01-012
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01169
Number of employers contributing to the scheme2022-01-010
2021: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01154
Total number of active participants reported on line 7a of the Form 55002021-01-01130
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 participants2021-01-01130
Number of employers contributing to the scheme2021-01-010
2020: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01163
Total number of active participants reported on line 7a of the Form 55002020-01-01154
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 participants2020-01-01154
Number of employers contributing to the scheme2020-01-010
2019: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01233
Total number of active participants reported on line 7a of the Form 55002019-01-01163
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 participants2019-01-01163
Number of employers contributing to the scheme2019-01-010
2018: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01201
Total number of active participants reported on line 7a of the Form 55002018-01-01233
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01233
Number of employers contributing to the scheme2018-01-010
2017: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01151
Total number of active participants reported on line 7a of the Form 55002017-01-01201
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 participants2017-01-01201
2016: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01166
Total number of active participants reported on line 7a of the Form 55002016-01-01151
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01151
2015: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01152
Total number of active participants reported on line 7a of the Form 55002015-01-01166
Number of retired or separated participants receiving benefits2015-01-011
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01167
2014: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01125
Total number of active participants reported on line 7a of the Form 55002014-01-01152
Number of retired or separated participants receiving benefits2014-01-012
Number of other retired or separated participants entitled to future benefits2014-01-011
Total of all active and inactive participants2014-01-01155
2013: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-02-01111
Total number of active participants reported on line 7a of the Form 55002013-02-01110
Number of retired or separated participants receiving benefits2013-02-010
Number of other retired or separated participants entitled to future benefits2013-02-010
Total of all active and inactive participants2013-02-01110
2012: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-02-01111
Total number of active participants reported on line 7a of the Form 55002012-02-01122
Number of retired or separated participants receiving benefits2012-02-012
Number of other retired or separated participants entitled to future benefits2012-02-010
Total of all active and inactive participants2012-02-01124

Form 5500 Responses for KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN

2022: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
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: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT 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: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT 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: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
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: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
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: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
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 funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-02-01Type of plan entitySingle employer plan
2013-02-01Submission has been amendedNo
2013-02-01This submission is the final filingNo
2013-02-01This return/report is a short plan year return/report (less than 12 months)Yes
2013-02-01Plan is a collectively bargained planNo
2013-02-01Plan funding arrangement – InsuranceYes
2013-02-01Plan funding arrangement – General assets of the sponsorYes
2013-02-01Plan benefit arrangement – InsuranceYes
2013-02-01Plan benefit arrangement – General assets of the sponsorYes
2012: KELLY, SCOTT AND MADISON, INC. EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-02-01Type of plan entitySingle employer plan
2012-02-01First time form 5500 has been submittedYes
2012-02-01Submission has been amendedNo
2012-02-01This submission is the final filingNo
2012-02-01This return/report is a short plan year return/report (less than 12 months)No
2012-02-01Plan is a collectively bargained planNo
2012-02-01Plan funding arrangement – InsuranceYes
2012-02-01Plan funding arrangement – General assets of the sponsorYes
2012-02-01Plan benefit arrangement – InsuranceYes
2012-02-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number120405
Policy instance 5
Insurance contract or identification number120405
Number of Individuals Covered167
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $16,994
Total amount of fees paid to insurance companyUSD $1,057
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLONG TERM CARE,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $99,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,994
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
WORKPLACE SOLUTIONS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 4
Insurance contract or identification numberEAP
Number of Individuals Covered130
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $3,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered103
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,139
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,139
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 2
Insurance contract or identification number10330
Number of Individuals Covered116
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,911
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $90,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,911
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 number0M1868
Policy instance 1
Insurance contract or identification number0M1868
Number of Individuals Covered181
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $61,408
Total amount of fees paid to insurance companyUSD $2,901
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,539,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $61,408
Amount paid for insurance broker fees2901
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS, NON-MONETARY COMPENSATION
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number0M1868
Policy instance 1
Insurance contract or identification number0M1868
Number of Individuals Covered183
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $52,520
Total amount of fees paid to insurance companyUSD $2,626
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,346,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,520
Amount paid for insurance broker fees2626
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS, NON-MONETARY COMPENATION
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 2
Insurance contract or identification number10330
Number of Individuals Covered104
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,073
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $101,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,073
Amount paid for insurance broker fees0
Insurance broker organization code?3
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered89
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,142
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,142
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 number120405
Policy instance 5
Insurance contract or identification number120405
Number of Individuals Covered123
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $15,513
Total amount of fees paid to insurance companyUSD $867
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLONG TERM CARE,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $100,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,513
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
WORKPLACE SOLUTIONS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 4
Insurance contract or identification numberEAP
Number of Individuals Covered130
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $1,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number0M1868
Policy instance 1
Insurance contract or identification number0M1868
Number of Individuals Covered194
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $58,617
Total amount of fees paid to insurance companyUSD $3,250
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,520,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $58,617
Amount paid for insurance broker fees3250
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 number120405
Policy instance 5
Insurance contract or identification number120405
Number of Individuals Covered154
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $17,147
Total amount of fees paid to insurance companyUSD $999
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLONG TERM CARE,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $105,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,147
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 2
Insurance contract or identification number10330
Number of Individuals Covered115
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,891
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $105,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,891
Amount paid for insurance broker fees0
Insurance broker organization code?3
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered94
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,083
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,083
Amount paid for insurance broker fees0
Insurance broker organization code?3
WORKPLACE SOLUTIONS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 4
Insurance contract or identification numberEAP
Number of Individuals Covered130
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $3,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number120405
Policy instance 5
Insurance contract or identification number120405
Number of Individuals Covered163
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $18,704
Total amount of fees paid to insurance companyUSD $1,084
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLONG TERM CARE,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $105,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,704
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
WORKPLACE SOLUTIONS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 4
Insurance contract or identification numberEAP
Number of Individuals Covered130
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $3,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered100
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,199
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,199
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 2
Insurance contract or identification number10330
Number of Individuals Covered126
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,229
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $107,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,229
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 number0M1868
Policy instance 1
Insurance contract or identification number0M1868
Number of Individuals Covered205
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $54,297
Total amount of fees paid to insurance companyUSD $3,550
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,435,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $54,297
Amount paid for insurance broker fees3550
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 number120405
Policy instance 5
Insurance contract or identification number120405
Number of Individuals Covered202
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $17,568
Total amount of fees paid to insurance companyUSD $1,004
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLONG TERM CARE,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $117,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,568
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
WORKPLACE SOLUTIONS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 4
Insurance contract or identification numberEAP
Number of Individuals Covered130
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $3,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered121
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,301
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,301
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 2
Insurance contract or identification number10330
Number of Individuals Covered144
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $6,680
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $124,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $6,680
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 number0M1868
Policy instance 1
Insurance contract or identification number0M1868
Number of Individuals Covered233
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $61,152
Total amount of fees paid to insurance companyUSD $3,675
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,546,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $61,152
Amount paid for insurance broker fees3675
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 number120405
Policy instance 5
Insurance contract or identification number120405
Number of Individuals Covered217
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $21,955
Total amount of fees paid to insurance companyUSD $1,235
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLONG TERM CARE,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $136,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,955
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
WORKPLACE SOLUTIONS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 4
Insurance contract or identification numberEAP
Number of Individuals Covered130
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $3,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered128
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,354
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,354
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 2
Insurance contract or identification number10330
Number of Individuals Covered158
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $5,665
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $133,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,665
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number0M1868
Policy instance 1
Insurance contract or identification number0M1868
Number of Individuals Covered243
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $51,314
Total amount of fees paid to insurance companyUSD $3,763
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,551,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,314
Amount paid for insurance broker fees3750
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number0M1868
Policy instance 1
Insurance contract or identification number0M1868
Number of Individuals Covered196
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $40,845
Total amount of fees paid to insurance companyUSD $6
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,055,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,845
Amount paid for insurance broker fees6
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 2
Insurance contract or identification number10330
Number of Individuals Covered127
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $4,461
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare 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 $89,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,461
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered98
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $981
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $981
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number120405
Policy instance 4
Insurance contract or identification number120405
Number of Individuals Covered179
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $16,306
Total amount of fees paid to insurance companyUSD $1,231
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT LONG TERM CARE
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 $98,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,306
Insurance broker organization code?3
Amount paid for insurance broker fees1231
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
WORKPLACE SOLUTIONS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 5
Insurance contract or identification numberEAP
Number of Individuals Covered130
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
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 $3,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number120405
Policy instance 1
Insurance contract or identification number120405
Number of Individuals Covered160
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $14,688
Total amount of fees paid to insurance companyUSD $1,088
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT LONG TERM CARE
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 $84,213
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,688
Insurance broker organization code?3
Amount paid for insurance broker fees1088
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number0M1868
Policy instance 2
Insurance contract or identification number0M1868
Number of Individuals Covered195
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $36,120
Total amount of fees paid to insurance companyUSD $2,925
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $916,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $36,120
Amount paid for insurance broker fees2925
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered122
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $4,046
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare 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 $80,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,046
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number10330
Policy instance 4
Insurance contract or identification number10330
Number of Individuals Covered86
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $775
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $775
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
WORKPLACE SOLUTIONS, LLC (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 5
Insurance contract or identification numberEAP
Number of Individuals Covered135
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
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 $3,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROTEC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 15297 )
Policy contract number00
Policy instance 4
Insurance contract or identification number00
Number of Individuals Covered68
Insurance policy start date2013-02-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $171
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $171
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number10330
Policy instance 3
Insurance contract or identification number10330
Number of Individuals Covered102
Insurance policy start date2013-02-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,145
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare 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 $64,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $3,145
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number120405
Policy instance 1
Insurance contract or identification number120405
Number of Individuals Covered139
Insurance policy start date2013-02-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $8,621
Total amount of fees paid to insurance companyUSD $592
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT LONG TERM CARE
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 $42,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,621
Insurance broker organization code?3
Amount paid for insurance broker fees592
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number0M1868
Policy instance 2
Insurance contract or identification number0M1868
Number of Individuals Covered156
Insurance policy start date2013-02-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $26,505
Total amount of fees paid to insurance companyUSD $2,375
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $641,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $26,505
Amount paid for insurance broker fees2375
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number120405
Policy instance 1
Insurance contract or identification number120405
Number of Individuals Covered122
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $16,835
Total amount of fees paid to insurance companyUSD $1,336
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT LONG-TERM CARE
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 $102,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,835
Insurance broker organization code?3
Amount paid for insurance broker fees1336
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.

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