ATLAS OIL COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ATLAS OIL COMPANY WELFARE BENEFIT PLAN
| 2022: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Submission has been amended | No |
| 2022-07-01 | This submission is the final filing | No |
| 2022-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-07-01 | Plan is a collectively bargained plan | No |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Submission has been amended | No |
| 2021-07-01 | This submission is the final filing | No |
| 2021-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-07-01 | Plan is a collectively bargained plan | No |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Submission has been amended | No |
| 2020-07-01 | This submission is the final filing | No |
| 2020-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-07-01 | Plan is a collectively bargained plan | No |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Submission has been amended | No |
| 2019-07-01 | This submission is the final filing | No |
| 2019-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-07-01 | Plan is a collectively bargained plan | No |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Submission has been amended | No |
| 2018-07-01 | This submission is the final filing | No |
| 2018-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-07-01 | Plan is a collectively bargained plan | No |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | Yes |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: ATLAS OIL COMPANY WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 3 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $728 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,207 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $728 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 283327 |
| Policy instance | 1 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 595 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $83,037 | | Total amount of fees paid to insurance company | USD $3,799 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $83,037 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 283327 |
| Policy instance | 2 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $7,376 | | Total amount of fees paid to insurance company | USD $292 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,376 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| METROPOLITAN GENERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 39950 ) |
| Policy contract number | 6090222 |
| Policy instance | 8 |
| Insurance contract or identification number | 6090222 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $1,464 | | Total amount of fees paid to insurance company | USD $361 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,595 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,464 | | Amount paid for insurance broker fees | 18 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 328 |
| Policy instance | 4 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 575 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $6,002 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,929 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 910773 |
| Policy instance | 5 |
| Insurance contract or identification number | 910773 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $13,071 | | Total amount of fees paid to insurance company | USD $1,615 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 Carrier | USD $86,940 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,071 | | Amount paid for insurance broker fees | 1615 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 ) |
| Policy contract number | 6090222 |
| Policy instance | 6 |
| Insurance contract or identification number | 6090222 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $126 | | Total amount of fees paid to insurance company | USD $55 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,260 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 38 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1140375 |
| Policy instance | 7 |
| Insurance contract or identification number | 1140375 | | Number of Individuals Covered | 551 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $32,427 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $292,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,427 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 283327 |
| Policy instance | 1 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 589 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $70,361 | | Total amount of fees paid to insurance company | USD $6,214 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $70,361 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 283327 |
| Policy instance | 2 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $10,127 | | Total amount of fees paid to insurance company | USD $408 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,127 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 3 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $258 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $258 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 328 |
| Policy instance | 4 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 592 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $7,258 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,709 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 ) |
| Policy contract number | 6090222 |
| Policy instance | 6 |
| Insurance contract or identification number | 6090222 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $1,870 | | Total amount of fees paid to insurance company | USD $337 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,743 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 34 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1140375 |
| Policy instance | 7 |
| Insurance contract or identification number | 1140375 | | Number of Individuals Covered | 467 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $33,999 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $315,877 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,999 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 910773 |
| Policy instance | 5 |
| Insurance contract or identification number | 910773 | | Number of Individuals Covered | 372 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $18,535 | | Total amount of fees paid to insurance company | USD $5,521 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $101,199 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,892 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 283327 |
| Policy instance | 1 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 627 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $54,835 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Commission paid to Insurance Broker | USD $54,835 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 3 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $469 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,747 | | Commission paid to Insurance Broker | USD $469 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0328 |
| Policy instance | 4 |
| Insurance contract or identification number | 0328 | | Number of Individuals Covered | 653 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $7,681 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Commission paid to Insurance Broker | USD $7,681 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9788555 |
| Policy instance | 5 |
| Insurance contract or identification number | 9788555 | | Number of Individuals Covered | 597 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $10,425 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $30,091 | | Commission paid to Insurance Broker | USD $1,073 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 910773 |
| Policy instance | 6 |
| Insurance contract or identification number | 910773 | | Number of Individuals Covered | 483 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $55,272 | | Total amount of fees paid to insurance company | USD $8,977 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $357,841 | | Commission paid to Insurance Broker | USD $55,272 | | Amount paid for insurance broker fees | 8977 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 ) |
| Policy contract number | 6090222 |
| Policy instance | 7 |
| Insurance contract or identification number | 6090222 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,097 | | Total amount of fees paid to insurance company | USD $413 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,931 | | Commission paid to Insurance Broker | USD $1,373 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | 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 number | 283327 |
| Policy instance | 2 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $6,241 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Commission paid to Insurance Broker | USD $6,241 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | 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 number | 283327 |
| Policy instance | 1 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 699 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $51,859 | | Total amount of fees paid to insurance company | USD $5,445 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,859 | | Amount paid for insurance broker fees | 5445 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 910773 |
| Policy instance | 2 |
| Insurance contract or identification number | 910773 | | Number of Individuals Covered | 591 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $79,327 | | Total amount of fees paid to insurance company | USD $27,987 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $509,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $79,327 | | Amount paid for insurance broker fees | 27987 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 328 |
| Policy instance | 3 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 685 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $10,712 | | Total amount of fees paid to insurance company | USD $653 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,712 | | Amount paid for insurance broker fees | 653 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 ) |
| Policy contract number | 6090222 |
| Policy instance | 4 |
| Insurance contract or identification number | 6090222 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $3,179 | | Total amount of fees paid to insurance company | USD $704 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,789 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,179 | | Amount paid for insurance broker fees | 704 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9788555 |
| Policy instance | 5 |
| Insurance contract or identification number | 9788555 | | Number of Individuals Covered | 688 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $4,862 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $42,640 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,445 | | Insurance broker organization code? | 3 |
|
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 6 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $878 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,965 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $878 | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 283327 |
| Policy instance | 7 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $4,656 | | Total amount of fees paid to insurance company | USD $555 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,656 | | Amount paid for insurance broker fees | 555 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 283327 |
| Policy instance | 1 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $5,721 | | Total amount of fees paid to insurance company | USD $511 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,721 | | Amount paid for insurance broker fees | 511 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26298 ) |
| Policy contract number | 6090222 |
| Policy instance | 2 |
| Insurance contract or identification number | 6090222 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $2,765 | | Total amount of fees paid to insurance company | USD $541 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $29,190 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,765 | | Amount paid for insurance broker fees | 541 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 283327 |
| Policy instance | 4 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 1084 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $50,581 | | Total amount of fees paid to insurance company | USD $5,141 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,581 | | Amount paid for insurance broker fees | 5141 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 328 |
| Policy instance | 3 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 1003 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $8,589 | | Total amount of fees paid to insurance company | USD $446 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,589 | | Amount paid for insurance broker fees | 446 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 910773 |
| Policy instance | 5 |
| Insurance contract or identification number | 910773 | | Number of Individuals Covered | 493 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $63,105 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $473,871 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $63,105 | | Insurance broker organization code? | 3 |
|
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 6 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $1,054 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,354 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,054 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97885551 |
| Policy instance | 7 |
| Insurance contract or identification number | 97885551 | | Number of Individuals Covered | 1009 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $2,830 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,962 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,983 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 328 |
| Policy instance | 2 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 811 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $6,435 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97885551001 |
| Policy instance | 3 |
| Insurance contract or identification number | 97885551001 | | Number of Individuals Covered | 812 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $2,734 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,344 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 802238 |
| Policy instance | 4 |
| Insurance contract or identification number | 802238 | | Number of Individuals Covered | 351 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $7,900 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $65,995 | | 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 number | 283327 |
| Policy instance | 5 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $3,801 | | Total amount of fees paid to insurance company | USD $240 | | Health Insurance Welfare Benefit | Yes | | 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 number | 283327 |
| Policy instance | 6 |
| Insurance contract or identification number | 283327 | | Number of Individuals Covered | 845 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $40,698 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0865125 |
| Policy instance | 7 |
| Insurance contract or identification number | 0865125 | | Number of Individuals Covered | 325 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $33,665 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $236,885 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 1 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $541 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,530 | | 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 number | 0000328 |
| Policy instance | 2 |
| Insurance contract or identification number | 0000328 | | Number of Individuals Covered | 526 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $5,923 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,923 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9788555 |
| Policy instance | 12 |
| Insurance contract or identification number | 9788555 | | Number of Individuals Covered | 584 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,730 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,730 | | Insurance broker name | MCGRAW WENTWORTH |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 785841 S006 |
| Policy instance | 11 |
| Insurance contract or identification number | 785841 S006 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1 | | 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: 12208 ) |
| Policy contract number | 785841 S003 |
| Policy instance | 10 |
| Insurance contract or identification number | 785841 S003 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,212 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $49,700 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,212 | | Insurance broker name | MCGRAW, THOMAS P |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 785841 S005 |
| Policy instance | 9 |
| Insurance contract or identification number | 785841 S005 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,376 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,545 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,376 | | Insurance broker name | MCGRAW, THOMAS P |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 785841 S006 |
| Policy instance | 8 |
| Insurance contract or identification number | 785841 S006 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $891 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,014 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $891 | | Insurance broker name | MCGRAW, THOMAS P |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 785841 S002 |
| Policy instance | 7 |
| Insurance contract or identification number | 785841 S002 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,989 | | 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: 12208 ) |
| Policy contract number | 785841 S004 |
| Policy instance | 6 |
| Insurance contract or identification number | 785841 S004 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $1,568 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $35,177 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,568 | | Insurance broker name | MCGRAW, THOMAS P |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0865125 |
| Policy instance | 5 |
| Insurance contract or identification number | 0865125 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $37,772 | | Total amount of fees paid to insurance company | USD $1,942 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $261,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,772 | | Amount paid for insurance broker fees | 1942 | | Additional information about fees paid to insurance broker | 2014/2015 PPP ENGAGEMENT CREDIT | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRAW WENTWORTH |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 785841 S0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 785841 S0001 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,154 | | 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: 12208 ) |
| Policy contract number | 785841 S001 |
| Policy instance | 13 |
| Insurance contract or identification number | 785841 S001 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $33,172 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $745,774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,172 | | Insurance broker name | MCGRAW, THOMAS P |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 785841 S004 |
| Policy instance | 14 |
| Insurance contract or identification number | 785841 S004 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $430 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 594730 |
| Policy instance | 4 |
| Insurance contract or identification number | 594730 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26 | | 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: 12208 ) |
| Policy contract number | 785841 S002 |
| Policy instance | 3 |
| Insurance contract or identification number | 785841 S002 | | Number of Individuals Covered | 457 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $94,513 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,125,808 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $94,513 | | Insurance broker name | MCGRAW, THOMAS P |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0865125 |
| Policy instance | 5 |
| Insurance contract or identification number | 0865125 | | Number of Individuals Covered | 432 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $34,738 | | Total amount of fees paid to insurance company | USD $3,996 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $275,449 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,738 | | Amount paid for insurance broker fees | 3996 | | Additional information about fees paid to insurance broker | 2013/2014 MM P3 BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRAW WENTWORTH |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0000328 |
| Policy instance | 3 |
| Insurance contract or identification number | 0000328 | | Number of Individuals Covered | 745 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $10,479 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,479 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 2 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,129 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,232 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,129 | | Insurance broker name | MCGRAW WENTWORTH |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 785841 S001 |
| Policy instance | 1 |
| Insurance contract or identification number | 785841 S001 | | Number of Individuals Covered | 943 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $149,991 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,380,883 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $149,991 | | Insurance broker name | MCGRAW, THOMAS P |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9788555 |
| Policy instance | 4 |
| Insurance contract or identification number | 9788555 | | Number of Individuals Covered | 746 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $3,208 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $34,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3208 | | Insurance broker name | MCGRAW WENTWORTH |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 785841S001 |
| Policy instance | 2 |
| Insurance contract or identification number | 785841S001 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,107 | | 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: 12208 ) |
| Policy contract number | 785841S001 |
| Policy instance | 3 |
| Insurance contract or identification number | 785841S001 | | Number of Individuals Covered | 734 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $133,411 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,700,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $133,411 | | Insurance broker name | THOMAS P. MCGRAW |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9788555 |
| Policy instance | 6 |
| Insurance contract or identification number | 9788555 | | Number of Individuals Covered | 620 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $2,559 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,526 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,559 | | Insurance broker name | MCGRAW WENTWORTH |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 328 |
| Policy instance | 5 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 619 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $7,941 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,539 | | Insurance broker name | MCGRAW WENTWORTH |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0865125 |
| Policy instance | 1 |
| Insurance contract or identification number | 0865125 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $32,112 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $246,522 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,112 | | Insurance broker name | MCGRAW WENTWORTH |
|
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 4 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $1,858 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,858 | | Insurance broker name | MCGRAW WENTWORTH |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 148528 |
| Policy instance | 1 |
| Insurance contract or identification number | 148528 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $22,938 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $135,724 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,404 | | Amount paid for insurance broker fees | 751 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 148529 |
| Policy instance | 2 |
| Insurance contract or identification number | 148529 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $11,157 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $66,165 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,469 | | Amount paid for insurance broker fees | 329 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 785841S001 |
| Policy instance | 3 |
| Insurance contract or identification number | 785841S001 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $45,043 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $900,854 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,584 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | NANCY SNELL |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 785841S001 |
| Policy instance | 4 |
| Insurance contract or identification number | 785841S001 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $62,518 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,241,302 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,822 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS P MCGRAW |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 328 |
| Policy instance | 5 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 541 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $9,603 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,251 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9788555 |
| Policy instance | 7 |
| Insurance contract or identification number | 9788555 | | Number of Individuals Covered | 485 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $2,149 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,641 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGRAW WENTWORTH |
|
| DENTEGRA INS CO (National Association of Insurance Commissioners NAIC id number: 73474 ) |
| Policy contract number | 76698 |
| Policy instance | 6 |
| Insurance contract or identification number | 76698 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,372 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,716 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,372 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFITS SERVICES |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 328 |
| Policy instance | 3 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 559 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $9,562 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 148528 |
| Policy instance | 1 |
| Insurance contract or identification number | 148528 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $17,504 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $112,469 | | 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: 12208 ) |
| Policy contract number | 785841S001 |
| Policy instance | 6 |
| Insurance contract or identification number | 785841S001 | | Number of Individuals Covered | 313 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $68,722 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,376,071 | | 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 number | 785841S001 |
| Policy instance | 5 |
| Insurance contract or identification number | 785841S001 | | Number of Individuals Covered | 209 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $31,780 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $635,601 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 148529 |
| Policy instance | 2 |
| Insurance contract or identification number | 148529 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $8,221 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $54,804 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9788555 |
| Policy instance | 4 |
| Insurance contract or identification number | 9788555 | | Number of Individuals Covered | 449 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $1,790 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,199 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9788555 |
| Policy instance | 5 |
| Insurance contract or identification number | 9788555 | | Number of Individuals Covered | 476 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $1,753 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,230 | | 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 number | 328 |
| Policy instance | 4 |
| Insurance contract or identification number | 328 | | Number of Individuals Covered | 562 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $7,773 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 148529 |
| Policy instance | 3 |
| Insurance contract or identification number | 148529 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $7,349 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $46,324 | | 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 number | 785841 S001 |
| Policy instance | 1 |
| Insurance contract or identification number | 785841 S001 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $82,476 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,649,529 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 148528 |
| Policy instance | 2 |
| Insurance contract or identification number | 148528 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $15,165 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $101,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
