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PENTASTAR AVIATION, LLC CAFETERIA PLAN 401k Plan overview

Plan NamePENTASTAR AVIATION, LLC CAFETERIA PLAN
Plan identification number 501

PENTASTAR AVIATION, LLC CAFETERIA 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

401k Sponsoring company profile

PENTASTAR AVIATION, LLC has sponsored the creation of one or more 401k plans.

Company Name:PENTASTAR AVIATION, LLC
Employer identification number (EIN):383622113
NAIC Classification:481000
NAIC Description: Air Transportation

Additional information about PENTASTAR AVIATION, LLC

Jurisdiction of Incorporation: Michigan Department of Licensing & Regulatory Affairs
Incorporation Date:
Company Identification Number: B3865A

More information about PENTASTAR AVIATION, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PENTASTAR AVIATION, LLC CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-11-01HEATHER A. SERMO2023-04-20
5012020-11-01HEATHER A. SERMO2022-05-25
5012019-11-01PATRICIA A. ZIKAKIS2021-03-17
5012018-11-01PATRICIA A. ZIKAKIS2020-08-17
5012017-11-01PATRICIA A. ZIKAKIS2019-05-21 GREGORY J. SCHMIDT2019-05-21
5012016-11-01
5012015-11-01
5012014-11-01
5012013-11-01GREGORY J SCHMIDT
5012012-11-01GREGORY J SCHMIDT
5012011-11-01LAURA FERICH
5012009-11-01GREG SCHMIDT
5012008-11-01

Plan Statistics for PENTASTAR AVIATION, LLC CAFETERIA PLAN

401k plan membership statisitcs for PENTASTAR AVIATION, LLC CAFETERIA PLAN

Measure Date Value
2021: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2021 401k membership
Total participants, beginning-of-year2021-11-01194
Total number of active participants reported on line 7a of the Form 55002021-11-01143
Number of retired or separated participants receiving benefits2021-11-015
Number of other retired or separated participants entitled to future benefits2021-11-016
Total of all active and inactive participants2021-11-01154
2020: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2020 401k membership
Total participants, beginning-of-year2020-11-01201
Total number of active participants reported on line 7a of the Form 55002020-11-01152
Number of retired or separated participants receiving benefits2020-11-016
Number of other retired or separated participants entitled to future benefits2020-11-013
Total of all active and inactive participants2020-11-01161
2019: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2019 401k membership
Total participants, beginning-of-year2019-11-01212
Total number of active participants reported on line 7a of the Form 55002019-11-01197
Number of retired or separated participants receiving benefits2019-11-011
Number of other retired or separated participants entitled to future benefits2019-11-012
Total of all active and inactive participants2019-11-01200
2018: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2018 401k membership
Total participants, beginning-of-year2018-11-01158
Total number of active participants reported on line 7a of the Form 55002018-11-01161
Number of retired or separated participants receiving benefits2018-11-013
Number of other retired or separated participants entitled to future benefits2018-11-012
Total of all active and inactive participants2018-11-01166
2017: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2017 401k membership
Total participants, beginning-of-year2017-11-01146
Total number of active participants reported on line 7a of the Form 55002017-11-01155
Number of retired or separated participants receiving benefits2017-11-013
Number of other retired or separated participants entitled to future benefits2017-11-014
Total of all active and inactive participants2017-11-01162
2016: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2016 401k membership
Total participants, beginning-of-year2016-11-01147
Total number of active participants reported on line 7a of the Form 55002016-11-01149
Number of retired or separated participants receiving benefits2016-11-011
Number of other retired or separated participants entitled to future benefits2016-11-011
Total of all active and inactive participants2016-11-01151
2015: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2015 401k membership
Total participants, beginning-of-year2015-11-01181
Total number of active participants reported on line 7a of the Form 55002015-11-01143
Number of retired or separated participants receiving benefits2015-11-014
Number of other retired or separated participants entitled to future benefits2015-11-010
Total of all active and inactive participants2015-11-01147
2014: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2014 401k membership
Total participants, beginning-of-year2014-11-01160
Total number of active participants reported on line 7a of the Form 55002014-11-01174
Number of retired or separated participants receiving benefits2014-11-017
Number of other retired or separated participants entitled to future benefits2014-11-010
Total of all active and inactive participants2014-11-01181
2013: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2013 401k membership
Total participants, beginning-of-year2013-11-01218
Total number of active participants reported on line 7a of the Form 55002013-11-01155
Number of retired or separated participants receiving benefits2013-11-015
Number of other retired or separated participants entitled to future benefits2013-11-010
Total of all active and inactive participants2013-11-01160
2012: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year2012-11-01250
Total number of active participants reported on line 7a of the Form 55002012-11-01212
Number of retired or separated participants receiving benefits2012-11-016
Number of other retired or separated participants entitled to future benefits2012-11-010
Total of all active and inactive participants2012-11-01218
2011: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year2011-11-01223
Total number of active participants reported on line 7a of the Form 55002011-11-01237
Number of retired or separated participants receiving benefits2011-11-0113
Number of other retired or separated participants entitled to future benefits2011-11-010
Total of all active and inactive participants2011-11-01250
2009: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2009 401k membership
Total participants, beginning-of-year2009-11-01234
Total number of active participants reported on line 7a of the Form 55002009-11-01205
Number of retired or separated participants receiving benefits2009-11-0114
Number of other retired or separated participants entitled to future benefits2009-11-010
Total of all active and inactive participants2009-11-01219

Form 5500 Responses for PENTASTAR AVIATION, LLC CAFETERIA PLAN

2021: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2021 form 5500 responses
2021-11-01Type of plan entitySingle employer plan
2021-11-01Submission has been amendedNo
2021-11-01This submission is the final filingNo
2021-11-01This return/report is a short plan year return/report (less than 12 months)No
2021-11-01Plan is a collectively bargained planNo
2021-11-01Plan funding arrangement – InsuranceYes
2021-11-01Plan funding arrangement – General assets of the sponsorYes
2021-11-01Plan benefit arrangement – InsuranceYes
2021-11-01Plan benefit arrangement – General assets of the sponsorYes
2020: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2020 form 5500 responses
2020-11-01Type of plan entitySingle employer plan
2020-11-01Submission has been amendedNo
2020-11-01This submission is the final filingNo
2020-11-01This return/report is a short plan year return/report (less than 12 months)No
2020-11-01Plan is a collectively bargained planNo
2020-11-01Plan funding arrangement – InsuranceYes
2020-11-01Plan funding arrangement – General assets of the sponsorYes
2020-11-01Plan benefit arrangement – InsuranceYes
2020-11-01Plan benefit arrangement – General assets of the sponsorYes
2019: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2019 form 5500 responses
2019-11-01Type of plan entitySingle employer plan
2019-11-01Submission has been amendedNo
2019-11-01This submission is the final filingNo
2019-11-01This return/report is a short plan year return/report (less than 12 months)No
2019-11-01Plan is a collectively bargained planNo
2019-11-01Plan funding arrangement – InsuranceYes
2019-11-01Plan funding arrangement – General assets of the sponsorYes
2019-11-01Plan benefit arrangement – InsuranceYes
2019-11-01Plan benefit arrangement – General assets of the sponsorYes
2018: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2018 form 5500 responses
2018-11-01Type of plan entitySingle employer plan
2018-11-01Submission has been amendedNo
2018-11-01This submission is the final filingNo
2018-11-01This return/report is a short plan year return/report (less than 12 months)No
2018-11-01Plan is a collectively bargained planNo
2018-11-01Plan funding arrangement – InsuranceYes
2018-11-01Plan funding arrangement – General assets of the sponsorYes
2018-11-01Plan benefit arrangement – InsuranceYes
2018-11-01Plan benefit arrangement – General assets of the sponsorYes
2017: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2017 form 5500 responses
2017-11-01Type of plan entitySingle employer plan
2017-11-01Submission has been amendedNo
2017-11-01This submission is the final filingNo
2017-11-01This return/report is a short plan year return/report (less than 12 months)No
2017-11-01Plan is a collectively bargained planNo
2017-11-01Plan funding arrangement – InsuranceYes
2017-11-01Plan funding arrangement – General assets of the sponsorYes
2017-11-01Plan benefit arrangement – InsuranceYes
2017-11-01Plan benefit arrangement – General assets of the sponsorYes
2016: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2016 form 5500 responses
2016-11-01Type of plan entitySingle employer plan
2016-11-01Submission has been amendedNo
2016-11-01This submission is the final filingNo
2016-11-01This return/report is a short plan year return/report (less than 12 months)No
2016-11-01Plan is a collectively bargained planNo
2016-11-01Plan funding arrangement – InsuranceYes
2016-11-01Plan funding arrangement – General assets of the sponsorYes
2016-11-01Plan benefit arrangement – InsuranceYes
2016-11-01Plan benefit arrangement – General assets of the sponsorYes
2015: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2015 form 5500 responses
2015-11-01Type of plan entitySingle employer plan
2015-11-01Submission has been amendedNo
2015-11-01This submission is the final filingNo
2015-11-01This return/report is a short plan year return/report (less than 12 months)No
2015-11-01Plan is a collectively bargained planNo
2015-11-01Plan funding arrangement – InsuranceYes
2015-11-01Plan funding arrangement – General assets of the sponsorYes
2015-11-01Plan benefit arrangement – InsuranceYes
2015-11-01Plan benefit arrangement – General assets of the sponsorYes
2014: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2014 form 5500 responses
2014-11-01Type of plan entitySingle employer plan
2014-11-01Submission has been amendedNo
2014-11-01This submission is the final filingNo
2014-11-01This return/report is a short plan year return/report (less than 12 months)No
2014-11-01Plan is a collectively bargained planNo
2014-11-01Plan funding arrangement – InsuranceYes
2014-11-01Plan funding arrangement – General assets of the sponsorYes
2014-11-01Plan benefit arrangement – InsuranceYes
2014-11-01Plan benefit arrangement – General assets of the sponsorYes
2013: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2013 form 5500 responses
2013-11-01Type of plan entitySingle employer plan
2013-11-01Submission has been amendedNo
2013-11-01This submission is the final filingNo
2013-11-01This return/report is a short plan year return/report (less than 12 months)No
2013-11-01Plan is a collectively bargained planNo
2013-11-01Plan funding arrangement – InsuranceYes
2013-11-01Plan funding arrangement – General assets of the sponsorYes
2013-11-01Plan benefit arrangement – InsuranceYes
2013-11-01Plan benefit arrangement – General assets of the sponsorYes
2012: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2012 form 5500 responses
2012-11-01Type of plan entitySingle employer plan
2012-11-01Submission has been amendedNo
2012-11-01This submission is the final filingNo
2012-11-01This return/report is a short plan year return/report (less than 12 months)No
2012-11-01Plan is a collectively bargained planNo
2012-11-01Plan funding arrangement – InsuranceYes
2012-11-01Plan funding arrangement – General assets of the sponsorYes
2012-11-01Plan benefit arrangement – InsuranceYes
2012-11-01Plan benefit arrangement – General assets of the sponsorYes
2011: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2011 form 5500 responses
2011-11-01Type of plan entitySingle employer plan
2011-11-01Submission has been amendedNo
2011-11-01This submission is the final filingNo
2011-11-01This return/report is a short plan year return/report (less than 12 months)No
2011-11-01Plan is a collectively bargained planNo
2011-11-01Plan funding arrangement – InsuranceYes
2011-11-01Plan funding arrangement – General assets of the sponsorYes
2011-11-01Plan benefit arrangement – InsuranceYes
2011-11-01Plan benefit arrangement – General assets of the sponsorYes
2009: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2009 form 5500 responses
2009-11-01Type of plan entitySingle employer plan
2009-11-01Submission has been amendedNo
2009-11-01This submission is the final filingNo
2009-11-01This return/report is a short plan year return/report (less than 12 months)No
2009-11-01Plan is a collectively bargained planNo
2009-11-01Plan funding arrangement – InsuranceYes
2009-11-01Plan funding arrangement – General assets of the sponsorYes
2009-11-01Plan benefit arrangement – InsuranceYes
2009-11-01Plan benefit arrangement – General assets of the sponsorYes
2008: PENTASTAR AVIATION, LLC CAFETERIA PLAN 2008 form 5500 responses
2008-11-01Type of plan entitySingle employer plan
2008-11-01Submission has been amendedNo
2008-11-01This submission is the final filingNo
2008-11-01This return/report is a short plan year return/report (less than 12 months)No
2008-11-01Plan is a collectively bargained planNo

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 2
Insurance contract or identification number30022366
Number of Individuals Covered135
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $1,054
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,054
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberEAB1000005
Policy instance 1
Insurance contract or identification numberEAB1000005
Number of Individuals Covered214
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $16,973
Total amount of fees paid to insurance companyUSD $5,234
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $189,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,973
Insurance broker organization code?3
Amount paid for insurance broker fees5234
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 2
Insurance contract or identification number30022366
Number of Individuals Covered127
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $1,194
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,194
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberEAB1000005
Policy instance 1
Insurance contract or identification numberEAB1000005
Number of Individuals Covered216
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $17,628
Total amount of fees paid to insurance companyUSD $7,252
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $201,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,628
Insurance broker organization code?3
Amount paid for insurance broker fees7252
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 2
Insurance contract or identification number30022366
Number of Individuals Covered136
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $1,053
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,053
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberEAB1000005
Policy instance 1
Insurance contract or identification numberEAB1000005
Number of Individuals Covered210
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $18,126
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $209,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,126
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberEAB1000005
Policy instance 1
Insurance contract or identification numberEAB1000005
Number of Individuals Covered222
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $16,976
Total amount of fees paid to insurance companyUSD $4,275
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $186,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,976
Amount paid for insurance broker fees4275
Additional information about fees paid to insurance brokerADD'L COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 2
Insurance contract or identification number30022366
Number of Individuals Covered141
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $1,123
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,359
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,123
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 2
Insurance contract or identification number30022366
Number of Individuals Covered145
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $1,281
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberEAB1000005
Policy instance 1
Insurance contract or identification numberEAB1000005
Number of Individuals Covered221
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $15,776
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $156,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 2
Insurance contract or identification number30022366
Number of Individuals Covered121
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $1,223
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,223
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number56234
Policy instance 3
Insurance contract or identification number56234
Number of Individuals Covered158
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberEAB1000005
Policy instance 1
Insurance contract or identification numberEAB1000005
Number of Individuals Covered193
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $22,274
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $145,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,274
Insurance broker organization code?3
Insurance broker nameLSG INSURANCE PARTNERS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0191D
Policy instance 2
Insurance contract or identification numberGLTD0191D
Number of Individuals Covered193
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $4,177
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $43,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,177
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 5
Insurance contract or identification number30022366
Number of Individuals Covered128
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $1,129
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,129
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5912440
Policy instance 4
Insurance contract or identification number5912440
Number of Individuals Covered344
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $3,688
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $118,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,457
Insurance broker organization code?3
Insurance broker nameLUBIN-SCHWARTZ & GOLDMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0191D
Policy instance 3
Insurance contract or identification numberGUG 0191D
Number of Individuals Covered193
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $1,035
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,035
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUGGVTL191D
Policy instance 1
Insurance contract or identification numberGLUGGVTL191D
Number of Individuals Covered193
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $8,907
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $68,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,907
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 5
Insurance contract or identification number30022366
Number of Individuals Covered152
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $1,307
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,307
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5912440
Policy instance 4
Insurance contract or identification number5912440
Number of Individuals Covered308
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $3,837
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $140,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,837
Insurance broker organization code?3
Insurance broker nameJAY SCHREIBMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0191D
Policy instance 3
Insurance contract or identification numberGUG 0191D
Number of Individuals Covered171
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $1,279
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,279
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0191D
Policy instance 2
Insurance contract or identification numberGLTD0191D
Number of Individuals Covered171
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $4,537
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $53,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,537
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUGGVTL191D
Policy instance 1
Insurance contract or identification numberGLUGGVTL191D
Number of Individuals Covered171
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $11,583
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $88,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,583
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 5
Insurance contract or identification number30022366
Number of Individuals Covered148
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $1,187
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,187
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUGGVTL191D
Policy instance 1
Insurance contract or identification numberGLUGGVTL191D
Number of Individuals Covered240
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $12,125
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $93,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,125
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDS0191D
Policy instance 4
Insurance contract or identification numberGUDS0191D
Number of Individuals Covered196
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $5,616
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $160,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,616
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0191D
Policy instance 3
Insurance contract or identification numberGUG 0191D
Number of Individuals Covered240
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $1,356
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,356
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0191D
Policy instance 2
Insurance contract or identification numberGLTD0191D
Number of Individuals Covered240
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $4,559
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $55,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,559
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 5
Insurance contract or identification number30022366
Number of Individuals Covered148
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $1,187
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDS0191D
Policy instance 4
Insurance contract or identification numberGUDS0191D
Number of Individuals Covered192
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $5,803
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $165,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0191D
Policy instance 3
Insurance contract or identification numberGUG 0191D
Number of Individuals Covered220
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $1,294
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0191D
Policy instance 2
Insurance contract or identification numberGLTD0191D
Number of Individuals Covered221
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $4,547
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $54,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUGGVTL191D
Policy instance 1
Insurance contract or identification numberGLUGGVTL191D
Number of Individuals Covered220
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $12,619
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $96,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUGGVTL191D
Policy instance 1
Insurance contract or identification numberGLUGGVTL191D
Number of Individuals Covered220
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $16,723
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $90,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0191D
Policy instance 3
Insurance contract or identification numberGUG 0191D
Number of Individuals Covered220
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $1,936
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDS0191D
Policy instance 4
Insurance contract or identification numberGUDS0191D
Number of Individuals Covered191
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $7,313
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $168,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30022366
Policy instance 5
Insurance contract or identification number30022366
Number of Individuals Covered142
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $1,113
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0191D
Policy instance 2
Insurance contract or identification numberGLTD0191D
Number of Individuals Covered220
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $7,279
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $51,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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