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WELLINGTON INDUSTRIES GROUP INS PLAN 401k Plan overview

Plan NameWELLINGTON INDUSTRIES GROUP INS PLAN
Plan identification number 501

WELLINGTON INDUSTRIES GROUP INS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Temporary disability (accident and sickness)
  • Long-term disability cover

401k Sponsoring company profile

WELLINGTON INDUSTRIES, INC. has sponsored the creation of one or more 401k plans.

Company Name:WELLINGTON INDUSTRIES, INC.
Employer identification number (EIN):381969533
NAIC Classification:332110

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WELLINGTON INDUSTRIES GROUP INS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-01-01
5012019-01-01
5012018-01-01
5012017-01-01MICHAEL SZYDLOWSKI
5012016-01-01MICHAEL SZYDLOWSKI
5012015-01-01MICHAEL SZYDLOWSKI
5012014-01-01MICHAEL SZYDLOWSKI
5012013-01-01MICHAEL SZYDLOWSKI MICHAEL SZYDLOWSKI2014-10-15
5012012-01-01MICHAEL SZYDLOWSKI
5012011-01-01MICHAEL SZYDLOWSKI
5012010-01-01MICHAEL SZYDLOWSKI
5012009-01-01MARVIN TYGHEM
5012009-01-01MARVIN TYGHEM
5012009-01-01MICHAEL C SZYDLOWSKI
5012009-01-01MARVIN TYGHEM
5012009-01-01MARVIN TYGHEM

Plan Statistics for WELLINGTON INDUSTRIES GROUP INS PLAN

401k plan membership statisitcs for WELLINGTON INDUSTRIES GROUP INS PLAN

Measure Date Value
2020: WELLINGTON INDUSTRIES GROUP INS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01208
Total number of active participants reported on line 7a of the Form 55002020-01-010
Total of all active and inactive participants2020-01-010
Total participants2020-01-010
2019: WELLINGTON INDUSTRIES GROUP INS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01208
Total number of active participants reported on line 7a of the Form 55002019-01-01208
Total of all active and inactive participants2019-01-01208
Total participants2019-01-01208
2018: WELLINGTON INDUSTRIES GROUP INS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01266
Total number of active participants reported on line 7a of the Form 55002018-01-01208
Total of all active and inactive participants2018-01-01208
Total participants2018-01-01208
2017: WELLINGTON INDUSTRIES GROUP INS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01276
Total number of active participants reported on line 7a of the Form 55002017-01-01266
Total of all active and inactive participants2017-01-01266
Total participants2017-01-01266
2016: WELLINGTON INDUSTRIES GROUP INS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01311
Total number of active participants reported on line 7a of the Form 55002016-01-01276
Total of all active and inactive participants2016-01-01276
Total participants2016-01-01276
2015: WELLINGTON INDUSTRIES GROUP INS PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01358
Total number of active participants reported on line 7a of the Form 55002015-01-01311
Total of all active and inactive participants2015-01-01311
Total participants2015-01-01311
2014: WELLINGTON INDUSTRIES GROUP INS PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01248
Total number of active participants reported on line 7a of the Form 55002014-01-01358
Total of all active and inactive participants2014-01-01358
Total participants2014-01-01358
2013: WELLINGTON INDUSTRIES GROUP INS PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01202
Total number of active participants reported on line 7a of the Form 55002013-01-01248
Number of retired or separated participants receiving benefits2013-01-010
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01248
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2013-01-010
Total participants2013-01-01248
Number of participants with account balances2013-01-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2013-01-010
2012: WELLINGTON INDUSTRIES GROUP INS PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01197
Total number of active participants reported on line 7a of the Form 55002012-01-01202
Number of retired or separated participants receiving benefits2012-01-010
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01202
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2012-01-010
Total participants2012-01-01202
Number of participants with account balances2012-01-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2012-01-010
2011: WELLINGTON INDUSTRIES GROUP INS PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01174
Total number of active participants reported on line 7a of the Form 55002011-01-01197
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01197
Total participants2011-01-01197
2010: WELLINGTON INDUSTRIES GROUP INS PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01125
Total number of active participants reported on line 7a of the Form 55002010-01-01174
Total of all active and inactive participants2010-01-01174
Total participants2010-01-01174
2009: WELLINGTON INDUSTRIES GROUP INS PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01101
Total number of active participants reported on line 7a of the Form 55002009-01-010
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2009-01-010

Form 5500 Responses for WELLINGTON INDUSTRIES GROUP INS PLAN

2020: WELLINGTON INDUSTRIES GROUP INS PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingYes
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: WELLINGTON INDUSTRIES GROUP INS PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: WELLINGTON INDUSTRIES GROUP INS PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: WELLINGTON INDUSTRIES GROUP INS PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: WELLINGTON INDUSTRIES GROUP INS PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: WELLINGTON INDUSTRIES GROUP INS PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: WELLINGTON INDUSTRIES GROUP INS PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: WELLINGTON INDUSTRIES GROUP INS PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: WELLINGTON INDUSTRIES GROUP INS PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: WELLINGTON INDUSTRIES GROUP INS PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2010: WELLINGTON INDUSTRIES GROUP INS PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: WELLINGTON INDUSTRIES GROUP INS PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingYes
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number243803
Policy instance 1
Insurance contract or identification number243803
Number of Individuals Covered0
Insurance policy start date2019-11-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $33,234
Total amount of fees paid to insurance companyUSD $33,234
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number243803
Policy instance 1
Insurance contract or identification number243803
Number of Individuals Covered352
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $33,234
Total amount of fees paid to insurance companyUSD $33,234
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $33,234
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG0000649G
Policy instance 1
Insurance contract or identification numberG0000649G
Number of Individuals Covered208
Insurance policy start date2017-11-01
Insurance policy end date2018-11-01
Total amount of commissions paid to insurance brokerUSD $24,080
Total amount of fees paid to insurance companyUSD $15,116
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $233,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,088
Amount paid for insurance broker fees15116
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000649G
Policy instance 1
Insurance contract or identification numberG000649G
Number of Individuals Covered266
Insurance policy start date2016-11-01
Insurance policy end date2017-11-01
Total amount of commissions paid to insurance brokerUSD $21,934
Total amount of fees paid to insurance companyUSD $13,433
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $235,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,934
Amount paid for insurance broker fees13433
Insurance broker organization code?3
Insurance broker nameJS CLARK AGENCY
UNITED OF OMAHA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000649G
Policy instance 1
Insurance contract or identification numberG000649G
Number of Individuals Covered311
Insurance policy start date2014-11-01
Insurance policy end date2015-11-01
Total amount of commissions paid to insurance brokerUSD $20,736
Total amount of fees paid to insurance companyUSD $12,026
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $235,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $77
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameJS CLARK AGENCY INC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number243803
Policy instance 2
Insurance contract or identification number243803
Number of Individuals Covered311
Insurance policy start date2014-11-01
Insurance policy end date2015-11-01
Total amount of commissions paid to insurance brokerUSD $403
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $93,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $403
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameJS CLARK AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000649G
Policy instance 1
Insurance contract or identification numberG000649G
Number of Individuals Covered248
Insurance policy start date2012-11-01
Insurance policy end date2013-11-01
Total amount of commissions paid to insurance brokerUSD $18,769
Total amount of fees paid to insurance companyUSD $27,809
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $18,769
Amount paid for insurance broker fees27809
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?1
Insurance broker nameJS CLARK AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000649G
Policy instance 1
Insurance contract or identification numberG000649G
Number of Individuals Covered202
Insurance policy start date2011-11-01
Insurance policy end date2012-11-01
Total amount of commissions paid to insurance brokerUSD $27,855
Total amount of fees paid to insurance companyUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,855
Amount paid for insurance broker fees0
Insurance broker nameJS CLARK AGENCY INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000649G
Policy instance 1
Insurance contract or identification numberG000649G
Number of Individuals Covered197
Insurance policy start date2010-11-01
Insurance policy end date2011-11-01
Total amount of commissions paid to insurance brokerUSD $18,847
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000649G
Policy instance 1
Insurance contract or identification numberG000649G
Number of Individuals Covered174
Insurance policy start date2009-11-01
Insurance policy end date2010-11-01
Total amount of commissions paid to insurance brokerUSD $36,862
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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