CITY BEVERAGE DBA LAKESHORE BEVERAGE has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN
Measure | Date | Value |
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2020: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 331 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 350 |
Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
Total of all active and inactive participants | 2020-01-01 | 350 |
2019: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 313 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 308 |
Number of retired or separated participants receiving benefits | 2019-01-01 | 3 |
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 | 311 |
2018: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-01-01 | 462 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 577 |
Number of retired or separated participants receiving benefits | 2018-01-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 3 |
Total of all active and inactive participants | 2018-01-01 | 583 |
2017: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-01-01 | 524 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 462 |
Number of retired or separated participants receiving benefits | 2017-01-01 | 2 |
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 | 464 |
2016: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-01-01 | 365 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 363 |
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 | 363 |
2015: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-01-01 | 358 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 355 |
Number of retired or separated participants receiving benefits | 2015-01-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 9 |
Total of all active and inactive participants | 2015-01-01 | 365 |
2014: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-01-01 | 380 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 366 |
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 | 366 |
2013: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-01-01 | 308 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 308 |
Number of retired or separated participants receiving benefits | 2013-01-01 | 4 |
Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 30 |
Total of all active and inactive participants | 2013-01-01 | 342 |
2012: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-01-01 | 271 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 271 |
Number of retired or separated participants receiving benefits | 2012-01-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 6 |
Total of all active and inactive participants | 2012-01-01 | 279 |
2011: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-01-01 | 239 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 290 |
Number of retired or separated participants receiving benefits | 2011-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
Total of all active and inactive participants | 2011-01-01 | 290 |
2010: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2010 401k membership |
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Total participants, beginning-of-year | 2010-10-01 | 239 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 239 |
Total of all active and inactive participants | 2010-10-01 | 239 |
2020: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2020 form 5500 responses |
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2020-01-01 | Type of plan entity | Single employer plan |
2020-01-01 | Submission has been amended | No |
2020-01-01 | This submission is the final filing | No |
2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-01-01 | Plan is a collectively bargained plan | No |
2020-01-01 | Plan funding arrangement – Insurance | Yes |
2020-01-01 | Plan benefit arrangement – Insurance | Yes |
2019: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
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2019-01-01 | Type of plan entity | Single employer plan |
2019-01-01 | Submission has been amended | Yes |
2019-01-01 | This submission is the final filing | No |
2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-01-01 | Plan is a collectively bargained plan | No |
2019-01-01 | Plan funding arrangement – Insurance | Yes |
2019-01-01 | Plan benefit arrangement – Insurance | Yes |
2018: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
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2018-01-01 | Type of plan entity | Single employer plan |
2018-01-01 | Submission has been amended | No |
2018-01-01 | This submission is the final filing | No |
2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-01-01 | Plan is a collectively bargained plan | No |
2018-01-01 | Plan funding arrangement – Insurance | Yes |
2018-01-01 | Plan benefit arrangement – Insurance | Yes |
2017: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
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2017-01-01 | Type of plan entity | Single employer plan |
2017-01-01 | Submission has been amended | No |
2017-01-01 | This submission is the final filing | No |
2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-01-01 | Plan is a collectively bargained plan | No |
2017-01-01 | Plan funding arrangement – Insurance | Yes |
2017-01-01 | Plan benefit arrangement – Insurance | Yes |
2016: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
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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 benefit arrangement – Insurance | Yes |
2015: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
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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 benefit arrangement – Insurance | Yes |
2014: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
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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 benefit arrangement – Insurance | Yes |
2013: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
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2013-01-01 | Type of plan entity | Single employer plan |
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 |
2012: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2012 form 5500 responses |
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2012-01-01 | Type of plan entity | Single employer plan |
2012-01-01 | Submission has been amended | No |
2012-01-01 | This submission is the final filing | No |
2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-01-01 | Plan is a collectively bargained plan | No |
2012-01-01 | Plan funding arrangement – Insurance | Yes |
2012-01-01 | Plan benefit arrangement – Insurance | Yes |
2011: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2011 form 5500 responses |
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2011-01-01 | Type of plan entity | Single employer plan |
2011-01-01 | Submission has been amended | No |
2011-01-01 | This submission is the final filing | No |
2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-01-01 | Plan is a collectively bargained plan | No |
2011-01-01 | Plan funding arrangement – Insurance | Yes |
2011-01-01 | Plan benefit arrangement – Insurance | Yes |
2010: LAKESHORE BEVERAGE EMPLOYEE BENEFITS PLAN 2010 form 5500 responses |
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2010-10-01 | Type of plan entity | Single employer plan |
2010-10-01 | Submission has been amended | No |
2010-10-01 | This submission is the final filing | No |
2010-10-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2010-10-01 | Plan is a collectively bargained plan | No |
2010-10-01 | Plan funding arrangement – Insurance | Yes |
2010-10-01 | Plan benefit arrangement – Insurance | Yes |
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00567867 |
Policy instance | 2 |
Insurance contract or identification number | 00567867 | Number of Individuals Covered | 365 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $40,298 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D, ACCIDENT, CRITICAL ILLNESS | 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 $287,674 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $40,298 | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 130322 |
Policy instance | 1 |
Insurance contract or identification number | 130322 | Number of Individuals Covered | 497 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $123,576 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $123,576 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BHT5 |
Policy instance | 9 |
Insurance contract or identification number | GVTL0BHT5 | Number of Individuals Covered | 146 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $6,857 | Total amount of fees paid to insurance company | USD $1,464 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SUPPLEMENTAL AND DEPENDENT LIFE, SUPPLEMENTAL AND DEPENDENT AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $45,713 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,438 | Amount paid for insurance broker fees | 1464 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0BHT5 |
Policy instance | 8 |
Insurance contract or identification number | GUG 0BHT5 | Number of Individuals Covered | 372 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $13,086 | Total amount of fees paid to insurance company | USD $2,224 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $87,242 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,469 | Amount paid for insurance broker fees | 2224 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDH0BHT5 |
Policy instance | 7 |
Insurance contract or identification number | GUDH0BHT5 | Number of Individuals Covered | 102 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,773 | Total amount of fees paid to insurance company | USD $536 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY ACCIDENT | 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 $11,822 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $683 | Amount paid for insurance broker fees | 536 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDE0BHT5 |
Policy instance | 6 |
Insurance contract or identification number | GUDE0BHT5 | Number of Individuals Covered | 70 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,996 | Total amount of fees paid to insurance company | USD $405 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY CRITICAL ILLNESS | 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 $13,310 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,055 | Amount paid for insurance broker fees | 405 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BHT5 |
Policy instance | 5 |
Insurance contract or identification number | GLUG0BHT5 | Number of Individuals Covered | 372 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $9,394 | Total amount of fees paid to insurance company | USD $3,766 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $62,625 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,642 | Amount paid for insurance broker fees | 1600 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BHT5 |
Policy instance | 4 |
Insurance contract or identification number | GLTD0BHT5 | Number of Individuals Covered | 372 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $7,895 | Total amount of fees paid to insurance company | USD $1,343 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $52,629 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,899 | Amount paid for insurance broker fees | 1343 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 3342539 |
Policy instance | 3 |
Insurance contract or identification number | 3342539 | Number of Individuals Covered | 297 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $15,715 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | 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 $228,757 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,960 | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
Policy contract number | P44630 P44712 |
Policy instance | 2 |
Insurance contract or identification number | P44630 P44712 | Number of Individuals Covered | 95 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $19,752 | Total amount of fees paid to insurance company | USD $450 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | 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 $455,679 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,643 | Amount paid for insurance broker fees | 450 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 130322 |
Policy instance | 1 |
Insurance contract or identification number | 130322 | Number of Individuals Covered | 386 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $71,490 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | 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 $4,356 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $44,938 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5941913 |
Policy instance | 4 |
Insurance contract or identification number | 5941913 | Number of Individuals Covered | 577 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $34,859 | Total amount of fees paid to insurance company | USD $6,058 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | 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 | AD&D, SUPPLEMENTAL LIFE & DEPENDENT LIFE, SUPPLEMENTAL AD&D & DEPENDENT AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $409,591 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $34,859 | Amount paid for insurance broker fees | 6058 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 0187214 |
Policy instance | 3 |
Insurance contract or identification number | 0187214 | Number of Individuals Covered | 0 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $5,064 | Total amount of fees paid to insurance company | USD $441 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS, ACCIDENT | 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 $22,689 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,064 | Amount paid for insurance broker fees | 441 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
Policy contract number | P44630 P44712 |
Policy instance | 2 |
Insurance contract or identification number | P44630 P44712 | Number of Individuals Covered | 96 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $15,962 | Total amount of fees paid to insurance company | USD $1,025 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | 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 $370,452 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,962 | Amount paid for insurance broker fees | 1025 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 130322 |
Policy instance | 1 |
Insurance contract or identification number | 130322 | Number of Individuals Covered | 450 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $62,635 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | 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 $5,436 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $62,635 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5941913 |
Policy instance | 3 |
Insurance contract or identification number | 5941913 | Number of Individuals Covered | 592 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $48,099 | Total amount of fees paid to insurance company | USD $4,120 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | 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 | AD&D, SUPPLEMENTAL AD&D, DEP AD&D, SUPPLEMENTAL LIFE, DEP LIFE, CRITICAL ILLNESS, ACCIDENT | 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 $442,616 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $48,099 | Amount paid for insurance broker fees | 4120 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | CBIZ BENEFITS & INS SERVICES INC |
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BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
Policy contract number | P44630 P44712 |
Policy instance | 2 |
Insurance contract or identification number | P44630 P44712 | Number of Individuals Covered | 80 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $12,747 | Total amount of fees paid to insurance company | USD $555 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | 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 $275,324 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,747 | Amount paid for insurance broker fees | 555 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 130322 |
Policy instance | 1 |
Insurance contract or identification number | 130322 | Number of Individuals Covered | 524 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $59,210 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | 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 $5,771 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $59,210 | Insurance broker organization code? | 3 | Insurance broker name | ANDY FIGLESTAHLER |
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