PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN
401k plan membership statisitcs for PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN
| Measure | Date | Value |
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| 2019: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2019 401k membership |
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| Total participants, beginning-of-year | 2019-01-01 | 742 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 0 |
| 2018: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 717 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 707 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 35 |
| Total of all active and inactive participants | 2018-01-01 | 742 |
| 2017: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 642 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 681 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 35 |
| Total of all active and inactive participants | 2017-01-01 | 716 |
| 2016: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2016 401k membership |
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| Total participants, beginning-of-year | 2016-01-01 | 589 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 602 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 41 |
| Total of all active and inactive participants | 2016-01-01 | 643 |
| 2015: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2015 401k membership |
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| Total participants, beginning-of-year | 2015-01-01 | 632 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 562 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 34 |
| Total of all active and inactive participants | 2015-01-01 | 596 |
| 2014: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2014 401k membership |
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| Total participants, beginning-of-year | 2014-09-01 | 635 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 592 |
| Number of retired or separated participants receiving benefits | 2014-09-01 | 40 |
| Total of all active and inactive participants | 2014-09-01 | 632 |
| 2009: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2009 401k membership |
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| Total participants, beginning-of-year | 2009-09-01 | 681 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 588 |
| Number of retired or separated participants receiving benefits | 2009-09-01 | 39 |
| Number of other retired or separated participants entitled to future benefits | 2009-09-01 | 0 |
| Total of all active and inactive participants | 2009-09-01 | 627 |
| 2019: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2019 form 5500 responses |
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| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | This submission is the final filing | Yes |
| 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: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2018 form 5500 responses |
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| 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: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2017 form 5500 responses |
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| 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: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2016 form 5500 responses |
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| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2014 form 5500 responses |
|---|
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2014-09-01 | Plan funding arrangement – Insurance | Yes |
| 2014-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: PASSAVANT MEMORIAL AREA HOSPITAL ASSOCIATION SALARY CONVERSION PLAN 2009 form 5500 responses |
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| 2009-09-01 | Type of plan entity | Single employer plan |
| 2009-09-01 | Submission has been amended | No |
| 2009-09-01 | This submission is the final filing | No |
| 2009-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-09-01 | Plan is a collectively bargained plan | No |
| 2009-09-01 | Plan funding arrangement – Insurance | Yes |
| 2009-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 70359-1 |
| Policy instance | 3 |
| Insurance contract or identification number | 70359-1 | | Number of Individuals Covered | 4057 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $56,432 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $351,040 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,432 | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 11039 |
| Policy instance | 2 |
| Insurance contract or identification number | 11039 | | Number of Individuals Covered | 537 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $28,358 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $378,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,358 | | Insurance broker organization code? | 3 |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 60790-1571 |
| Policy instance | 1 |
| Insurance contract or identification number | 60790-1571 | | Number of Individuals Covered | 1154 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $11,965 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $79,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,977 | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 11039 |
| Policy instance | 2 |
| Insurance contract or identification number | 11039 | | Number of Individuals Covered | 600 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $28,673 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $382,308 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,673 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL GROUP INC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466159 |
| Policy instance | 3 |
| Insurance contract or identification number | 466159 | | Number of Individuals Covered | 681 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $28,949 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL ACCIDENTAL DEATH & DIS | | Welfare Benefit Premiums Paid to Carrier | USD $192,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,949 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL GROUP INC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466160 |
| Policy instance | 4 |
| Insurance contract or identification number | 466160 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-11-01 | | Total amount of commissions paid to insurance broker | USD $17,288 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LIFESTYLE ADD, LIFESTYLE LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $115,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,288 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL GROUP INC |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 60790-1571 |
| Policy instance | 1 |
| Insurance contract or identification number | 60790-1571 | | Number of Individuals Covered | 1251 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $12,469 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,313 | | Insurance broker organization code? | 3 | | Insurance broker name | SELECT NETWORKS |
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| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 70359-1 |
| Policy instance | 5 |
| Insurance contract or identification number | 70359-1 | | Number of Individuals Covered | 2908 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $4,564 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $26,097 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,564 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL GROUP INC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466160 |
| Policy instance | 4 |
| Insurance contract or identification number | 466160 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $19,995 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LIFESTYLE ADD, LIFESTYLE LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $133,297 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,995 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL |
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| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 11039 |
| Policy instance | 2 |
| Insurance contract or identification number | 11039 | | Number of Individuals Covered | 447 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $21,351 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $284,683 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,351 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 60790-1571 |
| Policy instance | 1 |
| Insurance contract or identification number | 60790-1571 | | Number of Individuals Covered | 973 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $12,619 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,010 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHAEL W. CANFIELD |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466159 |
| Policy instance | 3 |
| Insurance contract or identification number | 466159 | | Number of Individuals Covered | 562 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $26,881 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL ACCIDENTAL DEATH & DIS | | Welfare Benefit Premiums Paid to Carrier | USD $179,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,881 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL GROUP INC |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 60790-1571 |
| Policy instance | 1 |
| Insurance contract or identification number | 60790-1571 | | Number of Individuals Covered | 914 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,818 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,212 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,121 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHAEL W. CANFIELD |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466160 |
| Policy instance | 4 |
| Insurance contract or identification number | 466160 | | Number of Individuals Covered | 312 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $4,137 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | LIFESTYLE ADD, LIFESTYLE LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $36,694 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,137 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466159 |
| Policy instance | 3 |
| Insurance contract or identification number | 466159 | | Number of Individuals Covered | 592 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $7,400 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL ACCIDENTAL DEATH & DIS | | Welfare Benefit Premiums Paid to Carrier | USD $65,416 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,400 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL GROUP INC |
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| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 11039 |
| Policy instance | 2 |
| Insurance contract or identification number | 11039 | | Number of Individuals Covered | 435 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $5,089 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $91,195 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,089 | | Insurance broker organization code? | 3 | | Insurance broker name | WESTLAKE FINANCIAL |
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| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F006953 FDL8929 |
| Policy instance | 3 |
| Insurance contract or identification number | F006953 FDL8929 | | Number of Individuals Covered | 632 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | No | | 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 $146,696 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 11039 |
| Policy instance | 1 |
| Insurance contract or identification number | 11039 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $2,787 | | 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 | 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 $37,163 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 60790-1571 |
| Policy instance | 2 |
| Insurance contract or identification number | 60790-1571 | | Number of Individuals Covered | 714 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $2,250 | | 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 $12,502 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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