APPLE TREE DENTAL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan APPLE TREE DENTAL HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-10-01 | 159 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-10-01 | 182 |
| Number of retired or separated participants receiving benefits | 2022-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-10-01 | 0 |
| Total of all active and inactive participants | 2022-10-01 | 182 |
| Number of employers contributing to the scheme | 2022-10-01 | 0 |
| 2021: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 172 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 159 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 163 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2020: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 172 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 172 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 144 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 144 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| Total participants, beginning-of-year | 2019-01-01 | 134 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 137 |
| 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 | 137 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 131 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 134 |
| 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 | 134 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 153 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 131 |
| 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 | 131 |
| 2016: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 157 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 153 |
| 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 | 153 |
| 2015: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 134 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 157 |
| 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 | 157 |
| 2014: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 134 |
| 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 | 134 |
| 2013: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 102 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 102 |
| 2022: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-10-01 | Type of plan entity | Single employer plan |
| 2022-10-01 | Plan funding arrangement – Insurance | Yes |
| 2022-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 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: APPLE TREE DENTAL HEALTH AND WELFARE 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: APPLE TREE DENTAL HEALTH AND WELFARE 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: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan 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: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan 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: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan 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 |
| 2013: APPLE TREE DENTAL HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | First time form 5500 has been submitted | Yes |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10249566 |
| Policy instance | 3 |
| Insurance contract or identification number | 10249566 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $20,767 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $138,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,767 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98557921001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98557921001 | | Number of Individuals Covered | 291 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $1,607 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,607 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 232541 |
| Policy instance | 1 |
| Insurance contract or identification number | 232541 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $8,319 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,048,602 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,319 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10249566 |
| Policy instance | 3 |
| Insurance contract or identification number | 10249566 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $18,627 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $124,177 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,627 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98557921001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98557921001 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,758 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,758 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 232541 |
| Policy instance | 1 |
| Insurance contract or identification number | 232541 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $28,100 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $942,817 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,100 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 232541 |
| Policy instance | 1 |
| Insurance contract or identification number | 232541 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $28,052 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $923,615 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,052 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98557921001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98557921001 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,614 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,820 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,146 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10249566 |
| Policy instance | 3 |
| Insurance contract or identification number | 10249566 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $19,519 | | Total amount of fees paid to insurance company | USD $2,537 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $130,123 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,519 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400249568 |
| Policy instance | 7 |
| Insurance contract or identification number | 400249568 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,630 | | Total amount of fees paid to insurance company | USD $177 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,868 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,630 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 403007269 |
| Policy instance | 6 |
| Insurance contract or identification number | 403007269 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $112 | | Total amount of fees paid to insurance company | USD $14 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $747 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $112 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10249567 |
| Policy instance | 5 |
| Insurance contract or identification number | 10249567 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $6,534 | | Total amount of fees paid to insurance company | USD $657 | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $43,560 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,534 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10249569 |
| Policy instance | 4 |
| Insurance contract or identification number | 10249569 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $6,183 | | Total amount of fees paid to insurance company | USD $636 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,218 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,183 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10249566 |
| Policy instance | 3 |
| Insurance contract or identification number | 10249566 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $770 | | Total amount of fees paid to insurance company | USD $78 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,136 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $770 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98557921001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98557921001 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,475 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,475 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 232541 |
| Policy instance | 1 |
| Insurance contract or identification number | 232541 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $23,895 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $820,946 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,895 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10249566 |
| Policy instance | 3 |
| Insurance contract or identification number | 10249566 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $11,618 | | Total amount of fees paid to insurance company | USD $5,293 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $77,453 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,618 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98557921001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98557921001 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $788 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $788 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 232541 |
| Policy instance | 1 |
| Insurance contract or identification number | 232541 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $16,453 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $613,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,453 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 160696 |
| Policy instance | 3 |
| Insurance contract or identification number | 160696 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $15,364 | | Total amount of fees paid to insurance company | USD $3,001 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,364 | | Amount paid for insurance broker fees | 1065 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98557921001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98557921001 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,204 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,027 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,204 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 232541 |
| Policy instance | 1 |
| Insurance contract or identification number | 232541 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $19,262 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $770,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,262 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 160696 |
| Policy instance | 3 |
| Insurance contract or identification number | 160696 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $19,758 | | Total amount of fees paid to insurance company | USD $2,437 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,758 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98557921001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98557921001 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,173 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,086 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,173 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) |
| Policy contract number | 232541 |
| Policy instance | 1 |
| Insurance contract or identification number | 232541 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $20,944 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $837,747 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,944 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| HEALTHPARTNERS (National Association of Insurance Commissioners NAIC id number: 95766 ) |
| Policy contract number | 966 |
| Policy instance | 1 |
| Insurance contract or identification number | 966 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $33,712 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE 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 Carrier | USD $877,738 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 33738 | | Additional information about fees paid to insurance broker | BROKER SERVICE FEE | | Insurance broker organization code? | 3 | | Insurance broker name | CORNELL INSURANCE SERVICES, INC. |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9855792 |
| Policy instance | 2 |
| Insurance contract or identification number | 9855792 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,117 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,479 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,117 | | Insurance broker organization code? | 3 | | Insurance broker name | DIRECT BENEFITS, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 211688/211689 |
| Policy instance | 3 |
| Insurance contract or identification number | 211688/211689 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $16,751 | | Total amount of fees paid to insurance company | USD $1,396 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $109,019 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,751 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1396 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 211688/211689 |
| Policy instance | 3 |
| Insurance contract or identification number | 211688/211689 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $9,351 | | Total amount of fees paid to insurance company | USD $490 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $62,344 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,882 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 490 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| HEALTHPARTNERS (National Association of Insurance Commissioners NAIC id number: 95766 ) |
| Policy contract number | 966 |
| Policy instance | 1 |
| Insurance contract or identification number | 966 | | Number of Individuals Covered | 321 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $28,256 | | Total amount of fees paid to insurance company | USD $585 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE 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 Carrier | USD $660,915 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,944 | | Amount paid for insurance broker fees | 351 | | Additional information about fees paid to insurance broker | PRODUCTION BONUS INDIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CORNELL INSURANCE SERVICES, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9855792 |
| Policy instance | 2 |
| Insurance contract or identification number | 9855792 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $823 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,451 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $337 | | Insurance broker organization code? | 3 | | Insurance broker name | DIRECT BENEFITS, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 211688/211689 |
| Policy instance | 3 |
| Insurance contract or identification number | 211688/211689 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $9,483 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,554 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,483 | | Insurance broker organization code? | 3 | | Insurance broker name | CORNELL INSURANCE SERVICES, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9855792 |
| Policy instance | 2 |
| Insurance contract or identification number | 9855792 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $863 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,998 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $575 | | Insurance broker organization code? | 3 | | Insurance broker name | DIRECT BENEFITS, INC. |
|
| HEALTHPARTNERS (National Association of Insurance Commissioners NAIC id number: 95766 ) |
| Policy contract number | 966 |
| Policy instance | 1 |
| Insurance contract or identification number | 966 | | Number of Individuals Covered | 228 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $25,714 | | Total amount of fees paid to insurance company | USD $1,145 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $569,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,714 | | Amount paid for insurance broker fees | 1145 | | Additional information about fees paid to insurance broker | PRODUCTION BONUS INDIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CORNELL INSURANCE SERVICES, INC. |
|
