SOMERSET OPERATING COMPANY LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC
401k plan membership statisitcs for THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC
| Measure | Date | Value |
|---|
| 2017: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 52 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 0 |
| Total participants | 2017-01-01 | 0 |
| 2016: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 50 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 42 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 10 |
| Total of all active and inactive participants | 2016-01-01 | 52 |
| Total participants | 2016-01-01 | 52 |
| 2015: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 35 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 40 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 10 |
| Total of all active and inactive participants | 2015-01-01 | 50 |
| Total participants | 2015-01-01 | 50 |
| 2014: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 49 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 23 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 12 |
| Total of all active and inactive participants | 2014-01-01 | 35 |
| Total participants | 2014-01-01 | 35 |
| 2013: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 53 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 39 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 10 |
| Total of all active and inactive participants | 2013-01-01 | 49 |
| Total participants | 2013-01-01 | 49 |
| 2012: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 44 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 40 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 13 |
| Total of all active and inactive participants | 2012-01-01 | 53 |
| Total participants | 2012-01-01 | 53 |
| 2011: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 44 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 33 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 5 |
| Total of all active and inactive participants | 2011-01-01 | 44 |
| Total participants | 2011-01-01 | 44 |
| Measure | Date | Value |
|---|
| 2017 : THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2017 401k financial data |
|---|
| Transfers to/from the plan | 2017-12-31 | $0 |
| Total plan liabilities at end of year | 2017-12-31 | $0 |
| Total plan liabilities at beginning of year | 2017-12-31 | $157,684 |
| Total income from all sources | 2017-12-31 | $61,426 |
| Expenses. Total of all expenses incurred | 2017-12-31 | $61,426 |
| Benefits paid (including direct rollovers) | 2017-12-31 | $61,065 |
| Total plan assets at end of year | 2017-12-31 | $0 |
| Total plan assets at beginning of year | 2017-12-31 | $157,684 |
| Value of fidelity bond covering the plan | 2017-12-31 | $500,000 |
| Total contributions received or receivable from participants | 2017-12-31 | $10,402 |
| Expenses. Other expenses not covered elsewhere | 2017-12-31 | $0 |
| Contributions received from other sources (not participants or employers) | 2017-12-31 | $0 |
| Other income received | 2017-12-31 | $11,726 |
| Noncash contributions received | 2017-12-31 | $0 |
| Net income (gross income less expenses) | 2017-12-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2017-12-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2017-12-31 | $0 |
| Total contributions received or receivable from employer(s) | 2017-12-31 | $39,298 |
| Value of certain deemed distributions of participant loans | 2017-12-31 | $0 |
| Value of corrective distributions | 2017-12-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2017-12-31 | $361 |
| 2016 : THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2016 401k financial data |
|---|
| Total plan liabilities at end of year | 2016-12-31 | $157,684 |
| Total plan liabilities at beginning of year | 2016-12-31 | $334,045 |
| Total income from all sources | 2016-12-31 | $252,975 |
| Expenses. Total of all expenses incurred | 2016-12-31 | $252,975 |
| Benefits paid (including direct rollovers) | 2016-12-31 | $251,636 |
| Total plan assets at end of year | 2016-12-31 | $157,684 |
| Total plan assets at beginning of year | 2016-12-31 | $334,045 |
| Value of fidelity bond covering the plan | 2016-12-31 | $500,000 |
| Total contributions received or receivable from participants | 2016-12-31 | $33,779 |
| Other income received | 2016-12-31 | $12,432 |
| Net income (gross income less expenses) | 2016-12-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2016-12-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2016-12-31 | $0 |
| Total contributions received or receivable from employer(s) | 2016-12-31 | $206,764 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2016-12-31 | $1,339 |
| 2015 : THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2015 401k financial data |
|---|
| Transfers to/from the plan | 2015-12-31 | $0 |
| Total plan liabilities at end of year | 2015-12-31 | $334,045 |
| Total plan liabilities at beginning of year | 2015-12-31 | $285,916 |
| Total income from all sources | 2015-12-31 | $71,304 |
| Expenses. Total of all expenses incurred | 2015-12-31 | $128,386 |
| Benefits paid (including direct rollovers) | 2015-12-31 | $126,409 |
| Total plan assets at end of year | 2015-12-31 | $334,045 |
| Total plan assets at beginning of year | 2015-12-31 | $342,998 |
| Value of fidelity bond covering the plan | 2015-12-31 | $500,000 |
| Total contributions received or receivable from participants | 2015-12-31 | $14,837 |
| Expenses. Other expenses not covered elsewhere | 2015-12-31 | $1,977 |
| Other income received | 2015-12-31 | $-6,976 |
| Net income (gross income less expenses) | 2015-12-31 | $-57,082 |
| Net plan assets at end of year (total assets less liabilities) | 2015-12-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2015-12-31 | $57,082 |
| Total contributions received or receivable from employer(s) | 2015-12-31 | $63,443 |
| 2014 : THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2014 401k financial data |
|---|
| Total plan liabilities at end of year | 2014-12-31 | $285,916 |
| Total plan liabilities at beginning of year | 2014-12-31 | $199,898 |
| Total income from all sources | 2014-12-31 | $39,752 |
| Expenses. Total of all expenses incurred | 2014-12-31 | $109,516 |
| Benefits paid (including direct rollovers) | 2014-12-31 | $107,523 |
| Total plan assets at end of year | 2014-12-31 | $342,998 |
| Total plan assets at beginning of year | 2014-12-31 | $326,744 |
| Value of fidelity bond covering the plan | 2014-12-31 | $500,000 |
| Total contributions received or receivable from participants | 2014-12-31 | $21,505 |
| Other income received | 2014-12-31 | $18,247 |
| Net income (gross income less expenses) | 2014-12-31 | $-69,764 |
| Net plan assets at end of year (total assets less liabilities) | 2014-12-31 | $57,082 |
| Net plan assets at beginning of year (total assets less liabilities) | 2014-12-31 | $126,846 |
| Total contributions received or receivable from employer(s) | 2014-12-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2014-12-31 | $1,993 |
| 2013 : THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2013 401k financial data |
|---|
| Total plan liabilities at end of year | 2013-12-31 | $199,898 |
| Total plan liabilities at beginning of year | 2013-12-31 | $124,092 |
| Total income from all sources | 2013-12-31 | $72,581 |
| Expenses. Total of all expenses incurred | 2013-12-31 | $96,568 |
| Benefits paid (including direct rollovers) | 2013-12-31 | $94,758 |
| Total plan assets at end of year | 2013-12-31 | $326,744 |
| Total plan assets at beginning of year | 2013-12-31 | $274,925 |
| Value of fidelity bond covering the plan | 2013-12-31 | $500,000 |
| Total contributions received or receivable from participants | 2013-12-31 | $18,952 |
| Other income received | 2013-12-31 | $53,629 |
| Net income (gross income less expenses) | 2013-12-31 | $-23,987 |
| Net plan assets at end of year (total assets less liabilities) | 2013-12-31 | $126,846 |
| Net plan assets at beginning of year (total assets less liabilities) | 2013-12-31 | $150,833 |
| Total contributions received or receivable from employer(s) | 2013-12-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2013-12-31 | $1,810 |
| 2012 : THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2012 401k financial data |
|---|
| Total plan liabilities at end of year | 2012-12-31 | $172,726 |
| Total plan liabilities at beginning of year | 2012-12-31 | $43,435 |
| Total income from all sources | 2012-12-31 | $208,262 |
| Expenses. Total of all expenses incurred | 2012-12-31 | $142,033 |
| Benefits paid (including direct rollovers) | 2012-12-31 | $140,540 |
| Total plan assets at end of year | 2012-12-31 | $274,925 |
| Total plan assets at beginning of year | 2012-12-31 | $79,405 |
| Value of fidelity bond covering the plan | 2012-12-31 | $500,000 |
| Total contributions received or receivable from participants | 2012-12-31 | $11,249 |
| Other income received | 2012-12-31 | $21,013 |
| Net income (gross income less expenses) | 2012-12-31 | $66,229 |
| Net plan assets at end of year (total assets less liabilities) | 2012-12-31 | $102,199 |
| Net plan assets at beginning of year (total assets less liabilities) | 2012-12-31 | $35,970 |
| Total contributions received or receivable from employer(s) | 2012-12-31 | $176,000 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2012-12-31 | $1,493 |
| 2011 : THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2011 401k financial data |
|---|
| Total plan liabilities at end of year | 2011-12-31 | $43,435 |
| Total plan liabilities at beginning of year | 2011-12-31 | $0 |
| Total income from all sources | 2011-12-31 | $2,496 |
| Expenses. Total of all expenses incurred | 2011-12-31 | $88,710 |
| Benefits paid (including direct rollovers) | 2011-12-31 | $87,688 |
| Total plan assets at end of year | 2011-12-31 | $79,405 |
| Total plan assets at beginning of year | 2011-12-31 | $122,184 |
| Value of fidelity bond covering the plan | 2011-12-31 | $500,000 |
| Expenses. Other expenses not covered elsewhere | 2011-12-31 | $1,022 |
| Other income received | 2011-12-31 | $2,496 |
| Net income (gross income less expenses) | 2011-12-31 | $-86,214 |
| Net plan assets at end of year (total assets less liabilities) | 2011-12-31 | $35,970 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-12-31 | $122,184 |
| 2017: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2017 form 5500 responses |
|---|
| 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 | Yes |
| 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 | Yes |
| 2017-01-01 | Plan funding arrangement – Trust | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 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 | Yes |
| 2016-01-01 | Plan funding arrangement – Trust | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 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 | Yes |
| 2015-01-01 | Plan funding arrangement – Trust | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 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 | Yes |
| 2014-01-01 | Plan funding arrangement – Trust | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2013 form 5500 responses |
|---|
| 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 | Yes |
| 2013-01-01 | Plan funding arrangement – Trust | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | Yes |
| 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 | Yes |
| 2012-01-01 | Plan funding arrangement – Trust | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: THE RETIREE MEDICAL PLAN OF SOMERSET OPERATING COMPANY, LLC 2011 form 5500 responses |
|---|
| 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 | Yes |
| 2011-01-01 | Plan funding arrangement – Trust | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00112678 |
| Policy instance | 1 |
| Insurance contract or identification number | 00112678 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $101,162 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $101,162 | | Insurance broker organization code? | 3 | | Insurance broker name | LIFETIME BENEFIT SOLUTIONS, INC. |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00112678 |
| Policy instance | 1 |
| Insurance contract or identification number | 00112678 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $114,121 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $114,121 | | Insurance broker organization code? | 3 | | Insurance broker name | MANNING & NAPIER BENEFITS LLC |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00112678 |
| Policy instance | 1 |
| Insurance contract or identification number | 00112678 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $17,827 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $17,827 | | Insurance broker organization code? | 3 | | Insurance broker name | MANNING & NAPIER BENEFITS, LLC |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00112678 |
| Policy instance | 1 |
| Insurance contract or identification number | 00112678 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $75,190 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | 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 | | 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 | | Commission paid to Insurance Broker | USD $13,007 | | Insurance broker organization code? | 3 | | Insurance broker name | BROWN & BROWN EMPIRE STATE |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 514353 |
| Policy instance | 2 |
| Insurance contract or identification number | 514353 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,234 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00340172 |
| Policy instance | 3 |
| Insurance contract or identification number | 00340172 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $12,292 | | Total amount of fees paid to insurance company | USD $9,479 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $201,862 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00112678 |
| Policy instance | 1 |
| Insurance contract or identification number | 00112678 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $30,648 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Amount paid for insurance broker fees | 30648 | | Insurance broker organization code? | 3 | | Insurance broker name | BROWN & BROWN EMPIRE STATE |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00017 |
| Policy instance | 1 |
| Insurance contract or identification number | 00017 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $9,262 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
