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UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 401k Plan overview

Plan NameUNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN
Plan identification number 502

UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN Benefits

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

401k Sponsoring company profile

UNIVERSITY PEDIATRICIANS has sponsored the creation of one or more 401k plans.

Company Name:UNIVERSITY PEDIATRICIANS
Employer identification number (EIN):383336414
NAIC Classification:621111
NAIC Description:Offices of Physicians (except Mental Health Specialists)

Additional information about UNIVERSITY PEDIATRICIANS

Jurisdiction of Incorporation: Michigan Secretary of State
Incorporation Date: 0000-00-00
Company Identification Number: 746859
Legal Registered Office Address: 3901 BEAUBIEN ST STE 1K40 DETROIT


United States of America (USA)
48201

More information about UNIVERSITY PEDIATRICIANS

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022020-01-01MARK HARRISON2021-10-08
5022019-01-01MARK HARRISON2020-12-03
5022018-01-01MARK HARRISON2019-10-14
5022017-01-01
5022016-01-01
5022015-01-01
5022014-01-01
5022013-01-01
5022012-01-01PATRICK SHUMAKER
5022011-01-01PATRICK SHUMAKER
5022010-01-01PATRICK SHUMAKER2014-07-02 PATRICK SHUMAKER2014-07-06
5022009-01-01PATRICK SHUMAKER PATRICK SHUMAKER2010-07-28

Plan Statistics for UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN

401k plan membership statisitcs for UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN

Measure Date Value
2020: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01639
Total number of active participants reported on line 7a of the Form 55002020-01-01665
Total of all active and inactive participants2020-01-01665
2019: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01454
Total number of active participants reported on line 7a of the Form 55002019-01-01639
Total of all active and inactive participants2019-01-01639
2018: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01460
Total number of active participants reported on line 7a of the Form 55002018-01-01454
Total of all active and inactive participants2018-01-01454
2017: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01444
Total number of active participants reported on line 7a of the Form 55002017-01-01460
Total of all active and inactive participants2017-01-01460
2016: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01402
Total number of active participants reported on line 7a of the Form 55002016-01-01444
Total of all active and inactive participants2016-01-01444
2015: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01385
Total number of active participants reported on line 7a of the Form 55002015-01-01402
Total of all active and inactive participants2015-01-01402
2014: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01377
Total number of active participants reported on line 7a of the Form 55002014-01-01385
Total of all active and inactive participants2014-01-01385
2013: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01370
Total number of active participants reported on line 7a of the Form 55002013-01-01377
Total of all active and inactive participants2013-01-01377
2012: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01327
Total number of active participants reported on line 7a of the Form 55002012-01-01370
Total of all active and inactive participants2012-01-01370
2011: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01345
Total number of active participants reported on line 7a of the Form 55002011-01-01327
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01327
2010: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01257
Total number of active participants reported on line 7a of the Form 55002010-01-01345
Number of retired or separated participants receiving benefits2010-01-010
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-01345
2009: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01238
Total number of active participants reported on line 7a of the Form 55002009-01-01257
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01257

Financial Data on UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN

Measure Date Value
2020 : UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2020 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Was this plan covered by a fidelity bond2020-12-31No
If this is an individual account plan, was there a blackout period2020-12-31No
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32020-12-31No
Did the plan have assets held for investment2020-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
2019 : UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2019 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Was this plan covered by a fidelity bond2019-12-31No
If this is an individual account plan, was there a blackout period2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32019-12-31No
Did the plan have assets held for investment2019-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
2018 : UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2018 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-12-31No
Was this plan covered by a fidelity bond2018-12-31No
If this is an individual account plan, was there a blackout period2018-12-31No
Were there any nonexempt tranactions with any party-in-interest2018-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2018-12-31No
Were any leases to which the plan was party in default or uncollectible2018-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-12-31No
Was there a failure to transmit to the plan any participant contributions2018-12-31No
Has the plan failed to provide any benefit when due under the plan2018-12-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32018-12-31No
Did the plan have assets held for investment2018-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-12-31No
2017 : UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2017 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-12-31No
Was this plan covered by a fidelity bond2017-12-31No
If this is an individual account plan, was there a blackout period2017-12-31No
Were there any nonexempt tranactions with any party-in-interest2017-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-12-31No
Were any leases to which the plan was party in default or uncollectible2017-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-12-31No
Was there a failure to transmit to the plan any participant contributions2017-12-31No
Has the plan failed to provide any benefit when due under the plan2017-12-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32017-12-31No
Did the plan have assets held for investment2017-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-12-31No
2016 : UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2016 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2016-12-31No
Was this plan covered by a fidelity bond2016-12-31No
If this is an individual account plan, was there a blackout period2016-12-31No
Were there any nonexempt tranactions with any party-in-interest2016-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2016-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2016-12-31No
Were any leases to which the plan was party in default or uncollectible2016-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2016-12-31No
Was there a failure to transmit to the plan any participant contributions2016-12-31No
Has the plan failed to provide any benefit when due under the plan2016-12-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32016-12-31No
Did the plan have assets held for investment2016-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2016-12-31No

Form 5500 Responses for UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN

2020: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedYes
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedYes
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2010: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedYes
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: UNIVERSITY PEDIATRICIANS LIFE, AD&D, & DISABILITY VISION, AND HEALTH PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158769
Policy instance 3
Insurance contract or identification number158769
Number of Individuals Covered358
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $64,452
Total amount of fees paid to insurance companyUSD $1,550
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $64,452
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number158769
Policy instance 4
Insurance contract or identification number158769
Number of Individuals Covered269
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $40,608
Total amount of fees paid to insurance companyUSD $1,494
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,608
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9289
Policy instance 2
Insurance contract or identification number9289
Number of Individuals Covered689
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $13,839
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,839
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97534681001
Policy instance 1
Insurance contract or identification number97534681001
Number of Individuals Covered679
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,982
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 number409960
Policy instance 5
Insurance contract or identification number409960
Number of Individuals Covered350
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $88,560
Total amount of fees paid to insurance companyUSD $5,882
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $433,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $88,560
Amount paid for insurance broker fees5882
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409960
Policy instance 5
Insurance contract or identification number409960
Number of Individuals Covered342
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $72,105
Total amount of fees paid to insurance companyUSD $4,841
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $396,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $72,105
Amount paid for insurance broker fees4841
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97534681001
Policy instance 1
Insurance contract or identification number97534681001
Number of Individuals Covered665
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $46,063
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 number9289
Policy instance 2
Insurance contract or identification number9289
Number of Individuals Covered660
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $12,777
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,641
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158769
Policy instance 3
Insurance contract or identification number158769
Number of Individuals Covered358
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $32,505
Total amount of fees paid to insurance companyUSD $1,688
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,505
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number158769
Policy instance 4
Insurance contract or identification number158769
Number of Individuals Covered271
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
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 number409960
Policy instance 2
Insurance contract or identification number409960
Number of Individuals Covered342
Insurance policy start date2020-07-01
Insurance policy end date2021-07-01
Total amount of commissions paid to insurance brokerUSD $62,479
Total amount of fees paid to insurance companyUSD $3,981
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $325,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $62,479
Amount paid for insurance broker fees3981
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409959
Policy instance 4
Insurance contract or identification number409959
Number of Individuals Covered299
Insurance policy start date2020-07-01
Insurance policy end date2021-07-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $14,541
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 number9289
Policy instance 5
Insurance contract or identification number9289
Number of Individuals Covered660
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $12,777
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,641
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97534681001
Policy instance 1
Insurance contract or identification number97534681001
Number of Individuals Covered665
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $46,063
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 number409961
Policy instance 3
Insurance contract or identification number409961
Number of Individuals Covered109
Insurance policy start date2020-07-01
Insurance policy end date2021-07-01
Total amount of commissions paid to insurance brokerUSD $9,626
Total amount of fees paid to insurance companyUSD $860
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFESTYLE AD&D, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to CarrierUSD $70,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,626
Amount paid for insurance broker fees860
Insurance broker organization code?1
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number158769
Policy instance 6
Insurance contract or identification number158769
Number of Individuals Covered309
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $21,834
Total amount of fees paid to insurance companyUSD $1,661
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,834
Insurance broker organization code?3
Amount paid for insurance broker fees1661
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409961
Policy instance 4
Insurance contract or identification number409961
Number of Individuals Covered97
Insurance policy start date2019-07-01
Insurance policy end date2020-07-01
Total amount of commissions paid to insurance brokerUSD $5,356
Total amount of fees paid to insurance companyUSD $478
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFESTYLE AD&D, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to CarrierUSD $41,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,356
Amount paid for insurance broker fees478
Insurance broker organization code?1
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409960
Policy instance 3
Insurance contract or identification number409960
Number of Individuals Covered324
Insurance policy start date2019-07-01
Insurance policy end date2020-07-01
Total amount of commissions paid to insurance brokerUSD $54,295
Total amount of fees paid to insurance companyUSD $3,497
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $287,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54,295
Amount paid for insurance broker fees3497
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158769
Policy instance 2
Insurance contract or identification number158769
Number of Individuals Covered288
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $17,299
Total amount of fees paid to insurance companyUSD $667
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,299
Insurance broker organization code?3
Amount paid for insurance broker fees667
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97534681001
Policy instance 1
Insurance contract or identification number97534681001
Number of Individuals Covered639
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $32,407
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 number409959
Policy instance 5
Insurance contract or identification number409959
Number of Individuals Covered299
Insurance policy start date2019-07-01
Insurance policy end date2020-07-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $14,541
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 number158769
Policy instance 6
Insurance contract or identification number158769
Number of Individuals Covered350
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $28,026
Total amount of fees paid to insurance companyUSD $2,019
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,026
Amount paid for insurance broker fees2019
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409959
Policy instance 5
Insurance contract or identification number409959
Number of Individuals Covered299
Insurance policy start date2018-07-01
Insurance policy end date2019-07-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $14,541
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 number409961
Policy instance 4
Insurance contract or identification number409961
Number of Individuals Covered33
Insurance policy start date2018-07-01
Insurance policy end date2019-07-01
Total amount of commissions paid to insurance brokerUSD $1,956
Total amount of fees paid to insurance companyUSD $175
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFESTYLE AD&D, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to CarrierUSD $14,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,956
Amount paid for insurance broker fees175
Insurance broker organization code?1
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409960
Policy instance 3
Insurance contract or identification number409960
Number of Individuals Covered346
Insurance policy start date2018-07-01
Insurance policy end date2019-07-01
Total amount of commissions paid to insurance brokerUSD $37,742
Total amount of fees paid to insurance companyUSD $2,463
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $198,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,742
Amount paid for insurance broker fees2463
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract numberGROUP 38154
Policy instance 2
Insurance contract or identification numberGROUP 38154
Number of Individuals Covered458
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $14,836
Total amount of fees paid to insurance companyUSD $399
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,836
Amount paid for insurance broker fees399
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97534681001
Policy instance 1
Insurance contract or identification number97534681001
Number of Individuals Covered454
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,176
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 numberGROUP 38154
Policy instance 2
Insurance contract or identification numberGROUP 38154
Insurance policy start date2016-07-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $26,308
Total amount of fees paid to insurance companyUSD $600
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,308
Amount paid for insurance broker fees600
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409960
Policy instance 3
Insurance contract or identification number409960
Number of Individuals Covered327
Insurance policy start date2017-07-01
Insurance policy end date2018-07-01
Total amount of commissions paid to insurance brokerUSD $39,613
Total amount of fees paid to insurance companyUSD $2,585
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $222,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,295
Amount paid for insurance broker fees2368
Insurance broker nameJS CLARK AGENCY INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409961
Policy instance 4
Insurance contract or identification number409961
Insurance policy start date2017-07-01
Insurance policy end date2018-07-01
Total amount of commissions paid to insurance brokerUSD $1,849
Total amount of fees paid to insurance companyUSD $165
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFESTYLE AD&D, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to CarrierUSD $14,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,682
Amount paid for insurance broker fees150
Insurance broker organization code?1
Insurance broker nameJS CLARK AGENCY INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number409959
Policy instance 5
Insurance contract or identification number409959
Number of Individuals Covered299
Insurance policy start date2017-07-01
Insurance policy end date2018-07-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $14,541
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 number158769
Policy instance 6
Insurance contract or identification number158769
Number of Individuals Covered350
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $28,026
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,026
Insurance broker nameKELLEY A. DEMIRYAN
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97534681001
Policy instance 1
Insurance contract or identification number97534681001
Number of Individuals Covered460
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $30,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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