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BUSCHS, INC. WELFARE BENEFITS PLAN 401k Plan overview

Plan NameBUSCHS, INC. WELFARE BENEFITS PLAN
Plan identification number 501

BUSCHS, INC. WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

BUSCH'S, INC. has sponsored the creation of one or more 401k plans.

Company Name:BUSCH'S, INC.
Employer identification number (EIN):382075818
NAIC Classification:445110
NAIC Description:Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BUSCHS, INC. WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-02-01
5012021-02-01
5012020-02-01
5012019-02-01
5012018-02-01
5012017-02-01CRISTY HESS
5012016-02-01CRISTY HESS
5012015-02-01CRISTY HESS
5012014-02-01CRISTY HESS
5012013-02-01CRISTY HESS
5012012-02-01JAMES W PETERSON
5012011-02-01JAMES PETERSON
5012010-02-01CHRISTINE BOOHER
5012009-02-01CHRISTINE BOOHER

Plan Statistics for BUSCHS, INC. WELFARE BENEFITS PLAN

401k plan membership statisitcs for BUSCHS, INC. WELFARE BENEFITS PLAN

Measure Date Value
2022: BUSCHS, INC. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-02-01554
Total number of active participants reported on line 7a of the Form 55002022-02-01633
Number of retired or separated participants receiving benefits2022-02-015
Number of other retired or separated participants entitled to future benefits2022-02-0167
Total of all active and inactive participants2022-02-01705
2021: BUSCHS, INC. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-02-01674
Total number of active participants reported on line 7a of the Form 55002021-02-01505
Number of retired or separated participants receiving benefits2021-02-014
Number of other retired or separated participants entitled to future benefits2021-02-0145
Total of all active and inactive participants2021-02-01554
2020: BUSCHS, INC. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-02-01698
Total number of active participants reported on line 7a of the Form 55002020-02-01667
Number of retired or separated participants receiving benefits2020-02-017
Number of other retired or separated participants entitled to future benefits2020-02-0145
Total of all active and inactive participants2020-02-01719
2019: BUSCHS, INC. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-02-01598
Total number of active participants reported on line 7a of the Form 55002019-02-01626
Number of retired or separated participants receiving benefits2019-02-011
Number of other retired or separated participants entitled to future benefits2019-02-0171
Total of all active and inactive participants2019-02-01698
2018: BUSCHS, INC. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-02-01605
Total number of active participants reported on line 7a of the Form 55002018-02-01598
Number of retired or separated participants receiving benefits2018-02-017
Number of other retired or separated participants entitled to future benefits2018-02-010
Total of all active and inactive participants2018-02-01605
2017: BUSCHS, INC. WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-02-01541
Total number of active participants reported on line 7a of the Form 55002017-02-01605
Number of retired or separated participants receiving benefits2017-02-014
Number of other retired or separated participants entitled to future benefits2017-02-010
Total of all active and inactive participants2017-02-01609
2016: BUSCHS, INC. WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-02-01492
Total number of active participants reported on line 7a of the Form 55002016-02-01541
Number of retired or separated participants receiving benefits2016-02-013
Number of other retired or separated participants entitled to future benefits2016-02-0115
Total of all active and inactive participants2016-02-01559
2015: BUSCHS, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-02-01471
Total number of active participants reported on line 7a of the Form 55002015-02-01492
Number of retired or separated participants receiving benefits2015-02-014
Number of other retired or separated participants entitled to future benefits2015-02-0113
Total of all active and inactive participants2015-02-01509
2014: BUSCHS, INC. WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-02-01914
Total number of active participants reported on line 7a of the Form 55002014-02-01548
Number of retired or separated participants receiving benefits2014-02-010
Number of other retired or separated participants entitled to future benefits2014-02-010
Total of all active and inactive participants2014-02-01548
2013: BUSCHS, INC. WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-02-01914
Total number of active participants reported on line 7a of the Form 55002013-02-01836
Number of retired or separated participants receiving benefits2013-02-010
Number of other retired or separated participants entitled to future benefits2013-02-010
Total of all active and inactive participants2013-02-01836
2012: BUSCHS, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-02-01897
Total number of active participants reported on line 7a of the Form 55002012-02-01902
Number of retired or separated participants receiving benefits2012-02-0112
Number of other retired or separated participants entitled to future benefits2012-02-010
Total of all active and inactive participants2012-02-01914
2011: BUSCHS, INC. WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-02-01849
Total number of active participants reported on line 7a of the Form 55002011-02-01897
Number of retired or separated participants receiving benefits2011-02-0111
Total of all active and inactive participants2011-02-01908
Total participants2011-02-01908
2010: BUSCHS, INC. WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-02-01841
Total number of active participants reported on line 7a of the Form 55002010-02-01849
Number of retired or separated participants receiving benefits2010-02-0113
Total of all active and inactive participants2010-02-01862
Total participants2010-02-01862
2009: BUSCHS, INC. WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-02-01807
Total number of active participants reported on line 7a of the Form 55002009-02-01841
Number of retired or separated participants receiving benefits2009-02-0115
Total of all active and inactive participants2009-02-01856
Total participants2009-02-01856

Form 5500 Responses for BUSCHS, INC. WELFARE BENEFITS PLAN

2022: BUSCHS, INC. WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01Submission has been amendedNo
2022-02-01This submission is the final filingNo
2022-02-01This return/report is a short plan year return/report (less than 12 months)No
2022-02-01Plan is a collectively bargained planNo
2022-02-01Plan funding arrangement – InsuranceYes
2022-02-01Plan benefit arrangement – InsuranceYes
2021: BUSCHS, INC. WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-02-01Type of plan entitySingle employer plan
2021-02-01Submission has been amendedNo
2021-02-01This submission is the final filingNo
2021-02-01This return/report is a short plan year return/report (less than 12 months)No
2021-02-01Plan is a collectively bargained planNo
2021-02-01Plan funding arrangement – InsuranceYes
2021-02-01Plan benefit arrangement – InsuranceYes
2020: BUSCHS, INC. WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-02-01Type of plan entitySingle employer plan
2020-02-01Submission has been amendedNo
2020-02-01This submission is the final filingNo
2020-02-01This return/report is a short plan year return/report (less than 12 months)No
2020-02-01Plan is a collectively bargained planNo
2020-02-01Plan funding arrangement – InsuranceYes
2020-02-01Plan benefit arrangement – InsuranceYes
2019: BUSCHS, INC. WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-02-01Type of plan entitySingle employer plan
2019-02-01Submission has been amendedNo
2019-02-01This submission is the final filingNo
2019-02-01This return/report is a short plan year return/report (less than 12 months)No
2019-02-01Plan is a collectively bargained planNo
2019-02-01Plan funding arrangement – InsuranceYes
2019-02-01Plan benefit arrangement – InsuranceYes
2018: BUSCHS, INC. WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-02-01Type of plan entitySingle employer plan
2018-02-01Submission has been amendedNo
2018-02-01This submission is the final filingNo
2018-02-01This return/report is a short plan year return/report (less than 12 months)No
2018-02-01Plan is a collectively bargained planNo
2018-02-01Plan funding arrangement – InsuranceYes
2018-02-01Plan benefit arrangement – InsuranceYes
2017: BUSCHS, INC. WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-02-01Type of plan entitySingle employer plan
2017-02-01Submission has been amendedNo
2017-02-01This submission is the final filingNo
2017-02-01This return/report is a short plan year return/report (less than 12 months)No
2017-02-01Plan is a collectively bargained planNo
2017-02-01Plan funding arrangement – InsuranceYes
2017-02-01Plan benefit arrangement – InsuranceYes
2016: BUSCHS, INC. WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-02-01Type of plan entitySingle employer plan
2016-02-01Submission has been amendedNo
2016-02-01This submission is the final filingNo
2016-02-01This return/report is a short plan year return/report (less than 12 months)No
2016-02-01Plan is a collectively bargained planNo
2016-02-01Plan funding arrangement – InsuranceYes
2016-02-01Plan benefit arrangement – InsuranceYes
2015: BUSCHS, INC. WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-02-01Type of plan entitySingle employer plan
2015-02-01Submission has been amendedNo
2015-02-01This submission is the final filingNo
2015-02-01This return/report is a short plan year return/report (less than 12 months)No
2015-02-01Plan is a collectively bargained planNo
2015-02-01Plan funding arrangement – InsuranceYes
2015-02-01Plan benefit arrangement – InsuranceYes
2014: BUSCHS, INC. WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-02-01Type of plan entitySingle employer plan
2014-02-01Submission has been amendedNo
2014-02-01This submission is the final filingNo
2014-02-01This return/report is a short plan year return/report (less than 12 months)No
2014-02-01Plan is a collectively bargained planNo
2014-02-01Plan funding arrangement – InsuranceYes
2014-02-01Plan benefit arrangement – InsuranceYes
2013: BUSCHS, INC. WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-02-01Type of plan entitySingle employer plan
2013-02-01Submission has been amendedNo
2013-02-01This submission is the final filingNo
2013-02-01This return/report is a short plan year return/report (less than 12 months)No
2013-02-01Plan is a collectively bargained planNo
2013-02-01Plan funding arrangement – InsuranceYes
2013-02-01Plan benefit arrangement – InsuranceYes
2012: BUSCHS, INC. WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-02-01Type of plan entitySingle employer plan
2012-02-01Submission has been amendedNo
2012-02-01This submission is the final filingNo
2012-02-01This return/report is a short plan year return/report (less than 12 months)No
2012-02-01Plan is a collectively bargained planNo
2012-02-01Plan funding arrangement – InsuranceYes
2012-02-01Plan benefit arrangement – InsuranceYes
2011: BUSCHS, INC. WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-02-01Type of plan entitySingle employer plan
2011-02-01First time form 5500 has been submittedYes
2011-02-01Submission has been amendedNo
2011-02-01This submission is the final filingNo
2011-02-01This return/report is a short plan year return/report (less than 12 months)No
2011-02-01Plan is a collectively bargained planNo
2011-02-01Plan funding arrangement – InsuranceYes
2011-02-01Plan benefit arrangement – InsuranceYes
2010: BUSCHS, INC. WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-02-01Type of plan entitySingle employer plan
2010-02-01Submission has been amendedYes
2010-02-01This submission is the final filingNo
2010-02-01This return/report is a short plan year return/report (less than 12 months)No
2010-02-01Plan is a collectively bargained planNo
2010-02-01Plan funding arrangement – InsuranceYes
2010-02-01Plan benefit arrangement – InsuranceYes
2009: BUSCHS, INC. WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-02-01Type of plan entitySingle employer plan
2009-02-01Submission has been amendedNo
2009-02-01This submission is the final filingNo
2009-02-01This return/report is a short plan year return/report (less than 12 months)No
2009-02-01Plan is a collectively bargained planNo
2009-02-01Plan funding arrangement – InsuranceYes
2009-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number795256
Policy instance 5
Insurance contract or identification number795256
Number of Individuals Covered677
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $81,908
Total amount of fees paid to insurance companyUSD $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 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 $3,276,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,908
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number3077
Policy instance 4
Insurance contract or identification number3077
Number of Individuals Covered712
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $6,484
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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 $64,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,484
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5554
Policy instance 3
Insurance contract or identification number5554
Number of Individuals Covered842
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $20,666
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,000
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX966603*
Policy instance 2
Insurance contract or identification numberFLX966603*
Number of Individuals Covered633
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $52,891
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY
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 $359,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,891
Insurance broker organization code?3
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )
Policy contract number795256
Policy instance 1
Insurance contract or identification number795256
Number of Individuals Covered125
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $20,451
Total amount of fees paid to insurance companyUSD $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 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 $818,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,451
Insurance broker organization code?3
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )
Policy contract number795256
Policy instance 1
Insurance contract or identification number795256
Number of Individuals Covered130
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $18,549
Total amount of fees paid to insurance companyUSD $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 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 $741,974
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,549
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX966603*
Policy instance 2
Insurance contract or identification numberFLX966603*
Number of Individuals Covered505
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $61,557
Total amount of fees paid to insurance companyUSD $3,066
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 BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY
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 $417,810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $61,475
Amount paid for insurance broker fees3066
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5554
Policy instance 3
Insurance contract or identification number5554
Number of Individuals Covered852
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $16,474
Total amount of fees paid to insurance companyUSD $611
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 BenefitYes
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,474
Amount paid for insurance broker fees611
Additional information about fees paid to insurance brokerRETENTION BONUS
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number3077
Policy instance 4
Insurance contract or identification number3077
Number of Individuals Covered429
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $5,970
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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 $59,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,970
Insurance broker organization code?3
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number795256
Policy instance 5
Insurance contract or identification number795256
Number of Individuals Covered676
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $77,056
Total amount of fees paid to insurance companyUSD $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 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 $3,009,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $77,056
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number3077
Policy instance 5
Insurance contract or identification number3077
Number of Individuals Covered418
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $6,371
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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 $63,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,842
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5554
Policy instance 4
Insurance contract or identification number5554
Number of Individuals Covered867
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $16,172
Total amount of fees paid to insurance companyUSD $447
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 BenefitYes
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
Commission paid to Insurance BrokerUSD $12,042
Insurance broker organization code?3
Amount paid for insurance broker fees447
Additional information about fees paid to insurance brokerRETENTION BONUS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX966603*
Policy instance 3
Insurance contract or identification numberFLX966603*
Number of Individuals Covered667
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $49,733
Total amount of fees paid to insurance companyUSD $2,974
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 BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT, HOSPITAL INDEMNITY
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 $336,282
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,350
Amount paid for insurance broker fees2974
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number224858
Policy instance 2
Insurance contract or identification number224858
Number of Individuals Covered0
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $34,180
Total amount of fees paid to insurance companyUSD $4,641
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,180
Insurance broker organization code?3
Amount paid for insurance broker fees4641
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS PAID
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number224858
Policy instance 1
Insurance contract or identification number224858
Number of Individuals Covered0
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $10,703
Total amount of fees paid to insurance companyUSD $759
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,703
Insurance broker organization code?3
Amount paid for insurance broker fees759
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS PAID
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number224858
Policy instance 1
Insurance contract or identification number224858
Number of Individuals Covered110
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $8,623
Total amount of fees paid to insurance companyUSD $752
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,623
Insurance broker organization code?3
Amount paid for insurance broker fees752
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS PAID
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number224858
Policy instance 2
Insurance contract or identification number224858
Number of Individuals Covered676
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $39,860
Total amount of fees paid to insurance companyUSD $4,348
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,860
Insurance broker organization code?3
Amount paid for insurance broker fees4348
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS PAID
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX966603*
Policy instance 3
Insurance contract or identification numberFLX966603*
Number of Individuals Covered626
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $52,636
Total amount of fees paid to insurance companyUSD $2,493
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 BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT, HOSPITAL
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 $358,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50,855
Amount paid for insurance broker fees2493
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number3077
Policy instance 5
Insurance contract or identification number3077
Number of Individuals Covered423
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $6,335
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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 $63,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,335
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5554
Policy instance 4
Insurance contract or identification number5554
Number of Individuals Covered856
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $16,434
Total amount of fees paid to insurance companyUSD $4,690
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 BenefitYes
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
Commission paid to Insurance BrokerUSD $16,434
Amount paid for insurance broker fees4690
Additional information about fees paid to insurance brokerNEW BUSINESS BONUS, RETENTION BONUS
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number224858
Policy instance 1
Insurance contract or identification number224858
Number of Individuals Covered72
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $6,222
Total amount of fees paid to insurance companyUSD $655
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,222
Insurance broker organization code?3
Amount paid for insurance broker fees655
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker nameWILLIS OF MICHIGAN
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number224858
Policy instance 2
Insurance contract or identification number224858
Number of Individuals Covered592
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $35,048
Total amount of fees paid to insurance companyUSD $4,678
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,048
Insurance broker organization code?3
Amount paid for insurance broker fees4678
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker nameWILLIS OF MICHIGAN INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX966603*
Policy instance 3
Insurance contract or identification numberFLX966603*
Number of Individuals Covered605
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $52,268
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $348,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,268
Insurance broker organization code?3
Insurance broker nameWILLIS OF MICHIGAN INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5554
Policy instance 4
Insurance contract or identification number5554
Number of Individuals Covered770
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $15,326
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
Commission paid to Insurance BrokerUSD $15,326
Insurance broker organization code?3
Insurance broker nameDEWEY, RAYMOND D.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number495742
Policy instance 5
Insurance contract or identification number495742
Number of Individuals Covered353
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $3,647
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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 $109,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,647
Insurance broker organization code?3
Insurance broker nameWILLIS OF MICHIGAN INC.
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number778440 S001
Policy instance 6
Insurance contract or identification number778440 S001
Number of Individuals Covered67
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $11,436
Total amount of fees paid to insurance companyUSD $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 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 $381,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,436
Insurance broker organization code?3
Insurance broker nameRAYMOND D. DEWEY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number404002602*
Policy instance 5
Insurance contract or identification number404002602*
Number of Individuals Covered80
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $10,644
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 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
Other welfare benefits providedACCIDENT, 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 CarrierUSD $31,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,456
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SVCS
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number778440 S001
Policy instance 7
Insurance contract or identification number778440 S001
Number of Individuals Covered112
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $17,664
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 $593,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,525
Insurance broker organization code?3
Insurance broker nameRAYOND D. DEWEY
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05996482
Policy instance 6
Insurance contract or identification numberTM05996482
Number of Individuals Covered707
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $15,460
Total amount of fees paid to insurance companyUSD $6,988
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 BenefitNo
Dental Insurance Welfare BenefitYes
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 $404,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,460
Amount paid for insurance broker fees6988
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameWILLIS OF MICHIGAN INC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number224858/001
Policy instance 2
Insurance contract or identification number224858/001
Number of Individuals Covered494
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $33,802
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 $2,183,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,802
Insurance broker organization code?3
Insurance broker nameWILLIS OF MICHIGAN INC.
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number07082
Policy instance 1
Insurance contract or identification number07082
Number of Individuals Covered67
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $16,906
Total amount of fees paid to insurance companyUSD $719
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,970
Insurance broker organization code?3
Amount paid for insurance broker fees719
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker nameWILLIS OF MICHIGAN
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number495742
Policy instance 4
Insurance contract or identification number495742
Number of Individuals Covered355
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $3,530
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
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 $101,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,530
Insurance broker organization code?3
Insurance broker nameWILLIS OF MICHIGAN INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX96603*
Policy instance 3
Insurance contract or identification numberFLX96603*
Number of Individuals Covered492
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $48,040
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 BenefitNo
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
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $320,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,040
Insurance broker organization code?3
Insurance broker nameWILLIS OF MICHIGAN INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05996482
Policy instance 5
Insurance contract or identification numberTM05996482
Number of Individuals Covered1131
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $16,147
Total amount of fees paid to insurance companyUSD $7,359
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 BenefitNo
Dental Insurance Welfare BenefitYes
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 $441,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,362
Insurance broker organization code?3
Amount paid for insurance broker fees681
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker nameWILLIS OF MICHIGAN, INC.
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number778440 S001
Policy instance 4
Insurance contract or identification number778440 S001
Number of Individuals Covered155
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $24,670
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 $832,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,861
Insurance broker organization code?3
Insurance broker nameJENNIFER JOHNSON
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number495742
Policy instance 7
Insurance contract or identification number495742
Number of Individuals Covered393
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $3,763
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
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 $117,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,763
Insurance broker organization code?3
Insurance broker nameWILLIS OF MICHIGAN INC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number224858/001
Policy instance 3
Insurance contract or identification number224858/001
Number of Individuals Covered518
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $33,664
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 $2,387,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,832
Insurance broker organization code?3
Insurance broker nameRUBIN TORREZ
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10169640*
Policy instance 1
Insurance contract or identification number10169640*
Number of Individuals Covered390
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $62,469
Total amount of fees paid to insurance companyUSD $11,514
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 BenefitNo
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
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $347,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $57,726
Insurance broker organization code?3
Amount paid for insurance broker fees11514
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker nameWELLS FARGO INS SVCS USA INC.
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number07082
Policy instance 6
Insurance contract or identification number07082
Number of Individuals Covered77
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $21,224
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,928
Insurance broker organization code?3
Insurance broker nameCONSTANCE REYNOLDS
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number686845
Policy instance 2
Insurance contract or identification number686845
Number of Individuals Covered561
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $36,782
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 BenefitNo
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
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $245,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,782
Insurance broker organization code?3
Insurance broker nameUNIVERSAL INS SERVICES
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10169640*
Policy instance 1
Insurance contract or identification number10169640*
Number of Individuals Covered449
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $53,643
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 BenefitNo
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
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $298,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,643
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SVCS USA INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3316148
Policy instance 3
Insurance contract or identification numberE3316148
Number of Individuals Covered116
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $1,076
Total amount of fees paid to insurance companyUSD $63
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 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
Other welfare benefits providedWORKSITE BENEFITS
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 $7,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $566
Amount paid for insurance broker fees37
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
Insurance broker nameMARY LOU TAYLOR
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number07082
Policy instance 8
Insurance contract or identification number07082
Number of Individuals Covered94
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $24,750
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,241
Insurance broker organization code?3
Insurance broker nameWELLS FARGO - GRAND RAPIDS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30018214
Policy instance 7
Insurance contract or identification number30018214
Number of Individuals Covered445
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $2,331
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
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
Commission paid to Insurance BrokerUSD $1,943
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SVCS USA, INC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05996482
Policy instance 6
Insurance contract or identification numberTM05996482
Number of Individuals Covered1211
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $15,880
Total amount of fees paid to insurance companyUSD $7,940
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 BenefitNo
Dental Insurance Welfare BenefitYes
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 $431,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,880
Insurance broker organization code?3
Amount paid for insurance broker fees7940
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker nameWELLS FARGO INS SVCS USA INC.
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number778440 S001
Policy instance 5
Insurance contract or identification number778440 S001
Number of Individuals Covered226
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $30,216
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 $1,009,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,674
Insurance broker organization code?3
Insurance broker nameJENNIFER JOHNSON
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number224858/001
Policy instance 4
Insurance contract or identification number224858/001
Number of Individuals Covered480
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $33,048
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
Other welfare benefits providedHEARING
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 $2,136,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,203
Insurance broker organization code?3
Insurance broker nameCONSTANCE REYNOLDS
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number677897G
Policy instance 2
Insurance contract or identification number677897G
Number of Individuals Covered890
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $6,862
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 BenefitNo
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees6862
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INS SVCS USA INC.
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number07082
Policy instance 2
Insurance contract or identification number07082
Number of Individuals Covered128
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $23,754
Total amount of fees paid to insurance companyUSD $1,150
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,754
Amount paid for insurance broker fees1150
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number224858/0001
Policy instance 3
Insurance contract or identification number224858/0001
Number of Individuals Covered519
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $34,957
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 $2,243,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,957
Insurance broker organization code?3
Insurance broker nameRAYMOND DEWEY
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5025
Policy instance 4
Insurance contract or identification number5025
Number of Individuals Covered1012
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $9,413
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 BenefitNo
Dental Insurance Welfare BenefitYes
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
Commission paid to Insurance BrokerUSD $9,413
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30018214
Policy instance 5
Insurance contract or identification number30018214
Number of Individuals Covered459
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $2,393
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
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
Commission paid to Insurance BrokerUSD $2,393
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number677897G
Policy instance 6
Insurance contract or identification number677897G
Number of Individuals Covered890
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $19,222
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 BenefitNo
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
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $310,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,222
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3316148
Policy instance 7
Insurance contract or identification numberE3316148
Number of Individuals Covered121
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $12,170
Total amount of fees paid to insurance companyUSD $607
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 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
Other welfare benefits providedCANCER AND 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 CarrierUSD $55,134
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,488
Amount paid for insurance broker fees56
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameBRUCE A. VAN RYN AND VARIOUS AGENTS
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number778440 S001
Policy instance 1
Insurance contract or identification number778440 S001
Number of Individuals Covered193
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $27,887
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 $929,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,887
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0005025
Policy instance 5
Insurance contract or identification number0005025
Number of Individuals Covered1040
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $10,327
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30018214
Policy instance 6
Insurance contract or identification number30018214
Number of Individuals Covered457
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $2,346
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3316148
Policy instance 7
Insurance contract or identification numberE3316148
Number of Individuals Covered120
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $11,375
Total amount of fees paid to insurance companyUSD $488
Other welfare benefits providedSUPPLEMENTAL CANCER AND ACCIDENT POLICIES
Welfare Benefit Premiums Paid to CarrierUSD $53,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number07082
Policy instance 4
Insurance contract or identification number07082
Number of Individuals Covered165
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $27,207
Total amount of fees paid to insurance companyUSD $1,952
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number778440 S001
Policy instance 3
Insurance contract or identification number778440 S001
Number of Individuals Covered194
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $24,118
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $803,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number677897G
Policy instance 2
Insurance contract or identification number677897G
Number of Individuals Covered890
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $17,356
Total amount of fees paid to insurance companyUSD $7,819
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $232,051
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 number00224858/0001
Policy instance 1
Insurance contract or identification number00224858/0001
Number of Individuals Covered542
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $36,524
Health Insurance Welfare BenefitYes
Other welfare benefits providedHEARING
Welfare Benefit Premiums Paid to CarrierUSD $1,815,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5025
Policy instance 5
Insurance contract or identification number5025
Number of Individuals Covered1005
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,596
Additional information about fees paid to insurance brokerBROKER COMMISSIONS
Insurance broker nameRAYMOND DEWEY
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number07082
Policy instance 4
Insurance contract or identification number07082
Number of Individuals Covered240
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $34,643
Total amount of fees paid to insurance companyUSD $5,051
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,357
Additional information about fees paid to insurance brokerAGENT/BROKER COMMISSION AND INCENTIVE PAYMENTS
Insurance broker organization code?3
Amount paid for insurance broker fees5051
Insurance broker nameWILLIAM J ROTHWELL
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30018214
Policy instance 6
Insurance contract or identification number30018214
Number of Individuals Covered449
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $2,337
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,337
Insurance broker nameWELLS FARGO INSURANCE AGENCY INC
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number778440 S001
Policy instance 3
Insurance contract or identification number778440 S001
Number of Individuals Covered103
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $20,701
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $690,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,701
Insurance broker nameRAYMOND DEWEY
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number677897G
Policy instance 2
Insurance contract or identification number677897G
Number of Individuals Covered890
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $250,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,635
Additional information about fees paid to insurance brokerBROKER COMMISSIONS
Insurance broker nameWELLS FARGO INS SVCS USA INC
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00224858/0001
Policy instance 1
Insurance contract or identification number00224858/0001
Number of Individuals Covered492
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $55,319
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,951,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $55,319
Additional information about fees paid to insurance brokerBROKER COMMISSION
Insurance broker nameRAYMOND DEWEY

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