PBBS EQUIPMENT CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PBBS EQUIPMENT CORPORATION HEALTH PLAN
| Measure | Date | Value |
|---|
| 2022: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-05-01 | 74 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-05-01 | 67 |
| Number of retired or separated participants receiving benefits | 2022-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-05-01 | 0 |
| Total of all active and inactive participants | 2022-05-01 | 67 |
| Total participants | 2022-05-01 | 67 |
| 2021: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-05-01 | 72 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-05-01 | 74 |
| Number of retired or separated participants receiving benefits | 2021-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-05-01 | 0 |
| Total of all active and inactive participants | 2021-05-01 | 74 |
| Total participants | 2021-05-01 | 74 |
| 2020: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-05-01 | 72 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-05-01 | 70 |
| Number of retired or separated participants receiving benefits | 2020-05-01 | 2 |
| Total of all active and inactive participants | 2020-05-01 | 72 |
| Total participants | 2020-05-01 | 72 |
| 2019: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-05-01 | 72 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 69 |
| Number of retired or separated participants receiving benefits | 2019-05-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2019-05-01 | 0 |
| Total of all active and inactive participants | 2019-05-01 | 72 |
| Total participants | 2019-05-01 | 72 |
| 2018: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-05-01 | 65 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 72 |
| Number of retired or separated participants receiving benefits | 2018-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-05-01 | 0 |
| Total of all active and inactive participants | 2018-05-01 | 72 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2018-05-01 | 0 |
| Total participants | 2018-05-01 | 72 |
| 2017: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-05-01 | 66 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 65 |
| Number of retired or separated participants receiving benefits | 2017-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-05-01 | 0 |
| Total of all active and inactive participants | 2017-05-01 | 65 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-05-01 | 0 |
| Total participants | 2017-05-01 | 65 |
| 2016: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-05-01 | 63 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 66 |
| Number of retired or separated participants receiving benefits | 2016-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-05-01 | 0 |
| Total of all active and inactive participants | 2016-05-01 | 66 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2016-05-01 | 0 |
| Total participants | 2016-05-01 | 66 |
| 2015: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-05-01 | 62 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 63 |
| Number of retired or separated participants receiving benefits | 2015-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-05-01 | 0 |
| Total of all active and inactive participants | 2015-05-01 | 63 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-05-01 | 0 |
| Total participants | 2015-05-01 | 63 |
| 2014: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-05-01 | 64 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-05-01 | 62 |
| Number of retired or separated participants receiving benefits | 2014-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-05-01 | 0 |
| Total of all active and inactive participants | 2014-05-01 | 62 |
| Total participants | 2014-05-01 | 62 |
| 2013: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 61 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 62 |
| Number of retired or separated participants receiving benefits | 2013-05-01 | 2 |
| Total of all active and inactive participants | 2013-05-01 | 64 |
| Total participants | 2013-05-01 | 64 |
| Number of participants with account balances | 2013-05-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2013-05-01 | 0 |
| 2012: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 63 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 59 |
| Number of retired or separated participants receiving benefits | 2012-05-01 | 2 |
| Total of all active and inactive participants | 2012-05-01 | 61 |
| Total participants | 2012-05-01 | 61 |
| Number of participants with account balances | 2012-05-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2012-05-01 | 0 |
| 2011: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-05-01 | 62 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 63 |
| Total of all active and inactive participants | 2011-05-01 | 63 |
| Total participants | 2011-05-01 | 63 |
| Number of participants with account balances | 2011-05-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2011-05-01 | 0 |
| 2010: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-05-01 | 64 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-05-01 | 62 |
| Total of all active and inactive participants | 2010-05-01 | 62 |
| Total participants | 2010-05-01 | 62 |
| Number of participants with account balances | 2010-05-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2010-05-01 | 0 |
| 2009: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-05-01 | 60 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-05-01 | 64 |
| Total of all active and inactive participants | 2009-05-01 | 64 |
| Total participants | 2009-05-01 | 64 |
| Number of participants with account balances | 2009-05-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2009-05-01 | 0 |
| Measure | Date | Value |
|---|
| 2023 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2023 401k financial data |
|---|
| Total income from all sources | 2023-04-30 | $1,095,791 |
| Expenses. Total of all expenses incurred | 2023-04-30 | $1,085,948 |
| Benefits paid (including direct rollovers) | 2023-04-30 | $1,084,995 |
| Total plan assets at end of year | 2023-04-30 | $10,843 |
| Total plan assets at beginning of year | 2023-04-30 | $1,000 |
| Value of fidelity bond covering the plan | 2023-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2023-04-30 | $195,071 |
| Other income received | 2023-04-30 | $207,057 |
| Net income (gross income less expenses) | 2023-04-30 | $9,843 |
| Net plan assets at end of year (total assets less liabilities) | 2023-04-30 | $10,843 |
| Net plan assets at beginning of year (total assets less liabilities) | 2023-04-30 | $1,000 |
| Total contributions received or receivable from employer(s) | 2023-04-30 | $693,663 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2023-04-30 | $953 |
| 2022 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2022 401k financial data |
|---|
| Total income from all sources | 2022-04-30 | $953,024 |
| Expenses. Total of all expenses incurred | 2022-04-30 | $953,024 |
| Benefits paid (including direct rollovers) | 2022-04-30 | $950,802 |
| Total plan assets at end of year | 2022-04-30 | $1,000 |
| Total plan assets at beginning of year | 2022-04-30 | $1,000 |
| Value of fidelity bond covering the plan | 2022-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2022-04-30 | $189,583 |
| Other income received | 2022-04-30 | $1,743 |
| Net income (gross income less expenses) | 2022-04-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2022-04-30 | $1,000 |
| Net plan assets at beginning of year (total assets less liabilities) | 2022-04-30 | $1,000 |
| Total contributions received or receivable from employer(s) | 2022-04-30 | $761,698 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2022-04-30 | $2,222 |
| 2021 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2021 401k financial data |
|---|
| Total income from all sources | 2021-04-30 | $977,081 |
| Expenses. Total of all expenses incurred | 2021-04-30 | $977,081 |
| Benefits paid (including direct rollovers) | 2021-04-30 | $953,488 |
| Total plan assets at end of year | 2021-04-30 | $1,000 |
| Total plan assets at beginning of year | 2021-04-30 | $1,000 |
| Value of fidelity bond covering the plan | 2021-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2021-04-30 | $219,177 |
| Other income received | 2021-04-30 | $144,274 |
| Net income (gross income less expenses) | 2021-04-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2021-04-30 | $1,000 |
| Net plan assets at beginning of year (total assets less liabilities) | 2021-04-30 | $1,000 |
| Total contributions received or receivable from employer(s) | 2021-04-30 | $613,630 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2021-04-30 | $23,593 |
| 2020 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2020 401k financial data |
|---|
| Total income from all sources | 2020-04-30 | $927,861 |
| Expenses. Total of all expenses incurred | 2020-04-30 | $927,861 |
| Benefits paid (including direct rollovers) | 2020-04-30 | $927,736 |
| Total plan assets at end of year | 2020-04-30 | $1,000 |
| Total plan assets at beginning of year | 2020-04-30 | $1,000 |
| Value of fidelity bond covering the plan | 2020-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2020-04-30 | $186,263 |
| Expenses. Other expenses not covered elsewhere | 2020-04-30 | $125 |
| Other income received | 2020-04-30 | $69,006 |
| Net income (gross income less expenses) | 2020-04-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2020-04-30 | $1,000 |
| Net plan assets at beginning of year (total assets less liabilities) | 2020-04-30 | $1,000 |
| Total contributions received or receivable from employer(s) | 2020-04-30 | $672,592 |
| 2018 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2018 401k financial data |
|---|
| Total income from all sources | 2018-04-30 | $1,045,202 |
| Expenses. Total of all expenses incurred | 2018-04-30 | $1,079,687 |
| Benefits paid (including direct rollovers) | 2018-04-30 | $1,076,010 |
| Total plan assets at end of year | 2018-04-30 | $1,000 |
| Total plan assets at beginning of year | 2018-04-30 | $35,485 |
| Value of fidelity bond covering the plan | 2018-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2018-04-30 | $166,063 |
| Expenses. Other expenses not covered elsewhere | 2018-04-30 | $3,677 |
| Other income received | 2018-04-30 | $155,169 |
| Net income (gross income less expenses) | 2018-04-30 | $-34,485 |
| Net plan assets at end of year (total assets less liabilities) | 2018-04-30 | $1,000 |
| Net plan assets at beginning of year (total assets less liabilities) | 2018-04-30 | $35,485 |
| Total contributions received or receivable from employer(s) | 2018-04-30 | $723,970 |
| 2017 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2017 401k financial data |
|---|
| Total income from all sources | 2017-04-30 | $1,010,502 |
| Expenses. Total of all expenses incurred | 2017-04-30 | $976,017 |
| Benefits paid (including direct rollovers) | 2017-04-30 | $975,840 |
| Total plan assets at end of year | 2017-04-30 | $35,485 |
| Total plan assets at beginning of year | 2017-04-30 | $1,000 |
| Value of fidelity bond covering the plan | 2017-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2017-04-30 | $162,732 |
| Other income received | 2017-04-30 | $93,479 |
| Net income (gross income less expenses) | 2017-04-30 | $34,485 |
| Net plan assets at end of year (total assets less liabilities) | 2017-04-30 | $35,485 |
| Net plan assets at beginning of year (total assets less liabilities) | 2017-04-30 | $1,000 |
| Total contributions received or receivable from employer(s) | 2017-04-30 | $754,291 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2017-04-30 | $177 |
| 2016 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2016 401k financial data |
|---|
| Total income from all sources | 2016-04-30 | $904,994 |
| Expenses. Total of all expenses incurred | 2016-04-30 | $904,994 |
| Benefits paid (including direct rollovers) | 2016-04-30 | $904,820 |
| Total plan assets at end of year | 2016-04-30 | $1,000 |
| Total plan assets at beginning of year | 2016-04-30 | $1,000 |
| Value of fidelity bond covering the plan | 2016-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2016-04-30 | $160,818 |
| Other income received | 2016-04-30 | $107,263 |
| Net income (gross income less expenses) | 2016-04-30 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2016-04-30 | $1,000 |
| Net plan assets at beginning of year (total assets less liabilities) | 2016-04-30 | $1,000 |
| Total contributions received or receivable from employer(s) | 2016-04-30 | $636,913 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2016-04-30 | $174 |
| 2015 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2015 401k financial data |
|---|
| Total income from all sources | 2015-04-30 | $859,214 |
| Expenses. Total of all expenses incurred | 2015-04-30 | $859,225 |
| Benefits paid (including direct rollovers) | 2015-04-30 | $856,869 |
| Total plan assets at end of year | 2015-04-30 | $1,000 |
| Total plan assets at beginning of year | 2015-04-30 | $1,011 |
| Value of fidelity bond covering the plan | 2015-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2015-04-30 | $152,660 |
| Other income received | 2015-04-30 | $80,189 |
| Net income (gross income less expenses) | 2015-04-30 | $-11 |
| Net plan assets at end of year (total assets less liabilities) | 2015-04-30 | $1,000 |
| Net plan assets at beginning of year (total assets less liabilities) | 2015-04-30 | $1,011 |
| Total contributions received or receivable from employer(s) | 2015-04-30 | $626,365 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2015-04-30 | $2,356 |
| 2014 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2014 401k financial data |
|---|
| Total income from all sources | 2014-04-30 | $1,196,408 |
| Expenses. Total of all expenses incurred | 2014-04-30 | $1,196,397 |
| Benefits paid (including direct rollovers) | 2014-04-30 | $1,179,205 |
| Total plan assets at end of year | 2014-04-30 | $1,011 |
| Total plan assets at beginning of year | 2014-04-30 | $1,000 |
| Value of fidelity bond covering the plan | 2014-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2014-04-30 | $182,035 |
| Other income received | 2014-04-30 | $415,007 |
| Net income (gross income less expenses) | 2014-04-30 | $11 |
| Net plan assets at end of year (total assets less liabilities) | 2014-04-30 | $1,011 |
| Net plan assets at beginning of year (total assets less liabilities) | 2014-04-30 | $1,000 |
| Total contributions received or receivable from employer(s) | 2014-04-30 | $599,366 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2014-04-30 | $17,192 |
| 2013 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2013 401k financial data |
|---|
| Total income from all sources | 2013-04-30 | $1,001,213 |
| Expenses. Total of all expenses incurred | 2013-04-30 | $1,000,499 |
| Benefits paid (including direct rollovers) | 2013-04-30 | $992,853 |
| Total plan assets at end of year | 2013-04-30 | $1,000 |
| Total plan assets at beginning of year | 2013-04-30 | $286 |
| Value of fidelity bond covering the plan | 2013-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2013-04-30 | $202,506 |
| Other income received | 2013-04-30 | $147,396 |
| Net income (gross income less expenses) | 2013-04-30 | $714 |
| Net plan assets at end of year (total assets less liabilities) | 2013-04-30 | $1,000 |
| Net plan assets at beginning of year (total assets less liabilities) | 2013-04-30 | $286 |
| Total contributions received or receivable from employer(s) | 2013-04-30 | $651,311 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2013-04-30 | $7,646 |
| 2012 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2012 401k financial data |
|---|
| Total income from all sources | 2012-04-30 | $1,150,295 |
| Expenses. Total of all expenses incurred | 2012-04-30 | $1,151,498 |
| Benefits paid (including direct rollovers) | 2012-04-30 | $1,150,186 |
| Total plan assets at end of year | 2012-04-30 | $286 |
| Total plan assets at beginning of year | 2012-04-30 | $1,489 |
| Value of fidelity bond covering the plan | 2012-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2012-04-30 | $180,433 |
| Other income received | 2012-04-30 | $265,915 |
| Net income (gross income less expenses) | 2012-04-30 | $-1,203 |
| Net plan assets at end of year (total assets less liabilities) | 2012-04-30 | $286 |
| Net plan assets at beginning of year (total assets less liabilities) | 2012-04-30 | $1,489 |
| Total contributions received or receivable from employer(s) | 2012-04-30 | $703,947 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2012-04-30 | $1,312 |
| 2011 : PBBS EQUIPMENT CORPORATION HEALTH PLAN 2011 401k financial data |
|---|
| Total plan liabilities at end of year | 2011-04-30 | $0 |
| Total plan liabilities at beginning of year | 2011-04-30 | $0 |
| Total income from all sources | 2011-04-30 | $744,391 |
| Expenses. Total of all expenses incurred | 2011-04-30 | $743,902 |
| Benefits paid (including direct rollovers) | 2011-04-30 | $741,779 |
| Total plan assets at end of year | 2011-04-30 | $1,489 |
| Total plan assets at beginning of year | 2011-04-30 | $1,000 |
| Value of fidelity bond covering the plan | 2011-04-30 | $500,000 |
| Total contributions received or receivable from participants | 2011-04-30 | $130,366 |
| Other income received | 2011-04-30 | $140,105 |
| Net income (gross income less expenses) | 2011-04-30 | $489 |
| Net plan assets at end of year (total assets less liabilities) | 2011-04-30 | $1,489 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-04-30 | $1,000 |
| Total contributions received or receivable from employer(s) | 2011-04-30 | $473,920 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2011-04-30 | $2,123 |
| 2022: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2022 form 5500 responses |
|---|
| 2022-05-01 | Type of plan entity | Single employer plan |
| 2022-05-01 | Submission has been amended | No |
| 2022-05-01 | This submission is the final filing | No |
| 2022-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-05-01 | Plan is a collectively bargained plan | No |
| 2022-05-01 | Plan funding arrangement – Insurance | Yes |
| 2022-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2021 form 5500 responses |
|---|
| 2021-05-01 | Type of plan entity | Single employer plan |
| 2021-05-01 | Submission has been amended | No |
| 2021-05-01 | This submission is the final filing | No |
| 2021-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-05-01 | Plan is a collectively bargained plan | No |
| 2021-05-01 | Plan funding arrangement – Insurance | Yes |
| 2021-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2020 form 5500 responses |
|---|
| 2020-05-01 | Type of plan entity | Single employer plan |
| 2020-05-01 | Submission has been amended | No |
| 2020-05-01 | This submission is the final filing | No |
| 2020-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-05-01 | Plan is a collectively bargained plan | No |
| 2020-05-01 | Plan funding arrangement – Insurance | Yes |
| 2020-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2019 form 5500 responses |
|---|
| 2019-05-01 | Type of plan entity | Single employer plan |
| 2019-05-01 | Submission has been amended | No |
| 2019-05-01 | This submission is the final filing | No |
| 2019-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-05-01 | Plan is a collectively bargained plan | No |
| 2019-05-01 | Plan funding arrangement – Insurance | Yes |
| 2019-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2018 form 5500 responses |
|---|
| 2018-05-01 | Type of plan entity | Single employer plan |
| 2018-05-01 | Submission has been amended | No |
| 2018-05-01 | This submission is the final filing | No |
| 2018-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-05-01 | Plan is a collectively bargained plan | No |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2017 form 5500 responses |
|---|
| 2017-05-01 | Type of plan entity | Single employer plan |
| 2017-05-01 | Submission has been amended | No |
| 2017-05-01 | This submission is the final filing | No |
| 2017-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-05-01 | Plan is a collectively bargained plan | No |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2016 form 5500 responses |
|---|
| 2016-05-01 | Type of plan entity | Single employer plan |
| 2016-05-01 | Submission has been amended | No |
| 2016-05-01 | This submission is the final filing | No |
| 2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-05-01 | Plan is a collectively bargained plan | No |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2015 form 5500 responses |
|---|
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Submission has been amended | No |
| 2015-05-01 | This submission is the final filing | No |
| 2015-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-05-01 | Plan is a collectively bargained plan | No |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2014 form 5500 responses |
|---|
| 2014-05-01 | Type of plan entity | Single employer plan |
| 2014-05-01 | Submission has been amended | No |
| 2014-05-01 | This submission is the final filing | No |
| 2014-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-05-01 | Plan is a collectively bargained plan | No |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Submission has been amended | No |
| 2013-05-01 | This submission is the final filing | No |
| 2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-05-01 | Plan is a collectively bargained plan | No |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | Submission has been amended | No |
| 2012-05-01 | This submission is the final filing | No |
| 2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-05-01 | Plan is a collectively bargained plan | No |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2011 form 5500 responses |
|---|
| 2011-05-01 | Type of plan entity | Single employer plan |
| 2011-05-01 | Submission has been amended | No |
| 2011-05-01 | This submission is the final filing | No |
| 2011-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-05-01 | Plan is a collectively bargained plan | No |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2010 form 5500 responses |
|---|
| 2010-05-01 | Type of plan entity | Single employer plan |
| 2010-05-01 | Submission has been amended | No |
| 2010-05-01 | This submission is the final filing | No |
| 2010-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-05-01 | Plan is a collectively bargained plan | No |
| 2010-05-01 | Plan funding arrangement – Insurance | Yes |
| 2010-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: PBBS EQUIPMENT CORPORATION HEALTH PLAN 2009 form 5500 responses |
|---|
| 2009-05-01 | Type of plan entity | Single employer plan |
| 2009-05-01 | Submission has been amended | No |
| 2009-05-01 | This submission is the final filing | No |
| 2009-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-05-01 | Plan is a collectively bargained plan | No |
| 2009-05-01 | Plan funding arrangement – Insurance | Yes |
| 2009-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 417002411578 |
| Policy instance | 3 |
| Insurance contract or identification number | 417002411578 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-12-01 | | Total amount of commissions paid to insurance broker | USD $18,810 | | Total amount of fees paid to insurance company | USD $234,131 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 199350 | | Additional information about fees paid to insurance broker | PHARMACY BENEFIT MANAGEMENT | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $9,276 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 41282 00000 |
| Policy instance | 2 |
| Insurance contract or identification number | 41282 00000 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2025-11-30 | | Total amount of commissions paid to insurance broker | USD $623 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,792 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 23808 01766 |
| Policy instance | 1 |
| Insurance contract or identification number | 23808 01766 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $3,516 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $45,876 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,516 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 417002411578 |
| Policy instance | 3 |
| Insurance contract or identification number | 417002411578 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-12-01 | | Total amount of commissions paid to insurance broker | USD $18,982 | | Total amount of fees paid to insurance company | USD $158,036 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 124577 | | Additional information about fees paid to insurance broker | PHARMACY BENEFIT MANAGEMENT | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $18,982 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 23808 01766 |
| Policy instance | 2 |
| Insurance contract or identification number | 23808 01766 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,549 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $44,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,549 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 41282 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 41282 00000 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $593 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,413 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $593 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 4128200000 |
| Policy instance | 1 |
| Insurance contract or identification number | 4128200000 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $694 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $694 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 2380801766 |
| Policy instance | 2 |
| Insurance contract or identification number | 2380801766 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,796 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $46,108 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,796 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 417002411578 |
| Policy instance | 3 |
| Insurance contract or identification number | 417002411578 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-12-01 | | Total amount of commissions paid to insurance broker | USD $20,528 | | Total amount of fees paid to insurance company | USD $59,061 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,528 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 59061 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 23808 01766 |
| Policy instance | 3 |
| Insurance contract or identification number | 23808 01766 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,736 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $48,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,736 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 417002411578 |
| Policy instance | 2 |
| Insurance contract or identification number | 417002411578 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-12-01 | | Total amount of commissions paid to insurance broker | USD $19,182 | | Total amount of fees paid to insurance company | USD $37,307 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,182 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 37307 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 41282 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 41282 00000 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $688 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,599 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $688 | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 417002411578 |
| Policy instance | 2 |
| Insurance contract or identification number | 417002411578 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-12-01 | | Total amount of commissions paid to insurance broker | USD $19,010 | | Total amount of fees paid to insurance company | USD $44,051 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,010 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 44051 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 2380801766 |
| Policy instance | 3 |
| Insurance contract or identification number | 2380801766 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,398 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $43,060 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,398 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 4128200000 |
| Policy instance | 1 |
| Insurance contract or identification number | 4128200000 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $644 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $644 | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 417002411578 |
| Policy instance | 1 |
| Insurance contract or identification number | 417002411578 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-12-01 | | Total amount of commissions paid to insurance broker | USD $18,495 | | Total amount of fees paid to insurance company | USD $44,983 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,495 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 44983 | | Insurance broker name | UMR INC. |
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| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 2380801766 |
| Policy instance | 3 |
| Insurance contract or identification number | 2380801766 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $3,281 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $40,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,281 | | Insurance broker organization code? | 3 | | Insurance broker name | INFINITY BENEFIT SOLUTIONS INC. |
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| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 4128200000 |
| Policy instance | 2 |
| Insurance contract or identification number | 4128200000 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2016-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $640 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,005 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $640 | | Insurance broker organization code? | 3 | | Insurance broker name | INFINITY BENEFIT SOLUTIONS INC. |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 417002411578 |
| Policy instance | 2 |
| Insurance contract or identification number | 417002411578 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $18,237 | | Total amount of fees paid to insurance company | USD $40,206 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,237 | | Amount paid for insurance broker fees | 18237 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | UMR INC. |
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| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 23808 01766 |
| Policy instance | 1 |
| Insurance contract or identification number | 23808 01766 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,950 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,147 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,950 | | Insurance broker organization code? | 3 | | Insurance broker name | INFINITY BENEFIT SOLUTIONS INC |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 417002411578 |
| Policy instance | 2 |
| Insurance contract or identification number | 417002411578 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-12-01 | | Total amount of commissions paid to insurance broker | USD $18,580 | | Total amount of fees paid to insurance company | USD $41,242 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,242 | | Amount paid for insurance broker fees | 41242 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEES | | Insurance broker organization code? | 5 | | Insurance broker name | INFINITIY BENEFIT SOLUTIONS INC. |
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| COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
| Policy contract number | 00137229 |
| Policy instance | 1 |
| Insurance contract or identification number | 00137229 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,260 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,253 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,260 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT ALLIANT LLC |
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| COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
| Policy contract number | 00137229 |
| Policy instance | 1 |
| Insurance contract or identification number | 00137229 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,385 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,385 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT ALLIANT LLC |
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| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL 19008 |
| Policy instance | 2 |
| Insurance contract or identification number | HCL 19008 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $23,043 | | Total amount of fees paid to insurance company | USD $20,591 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $656 | | Amount paid for insurance broker fees | 656 | | Additional information about fees paid to insurance broker | PROVIDER NETWORK | | Insurance broker organization code? | 5 | | Insurance broker name | JON PLAMANN & ASSOCIATES, INC |
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| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL 19008 |
| Policy instance | 2 |
| Insurance contract or identification number | HCL 19008 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $18,664 | | Total amount of fees paid to insurance company | USD $20,510 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,664 | | Amount paid for insurance broker fees | 18664 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | PREFERRED ONE |
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| COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
| Policy contract number | 00137229 |
| Policy instance | 1 |
| Insurance contract or identification number | 00137229 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,324 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,045 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,324 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT ALLIANT LLC |
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| COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
| Policy contract number | 00137229 |
| Policy instance | 1 |
| Insurance contract or identification number | 00137229 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,437 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,462 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 ) |
| Policy contract number | ERLL00100384004 |
| Policy instance | 2 |
| Insurance contract or identification number | ERLL00100384004 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of fees paid to insurance company | USD $35,083 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| BERKLEY HEALTH AND LIFE INSURANCE (National Association of Insurance Commissioners NAIC id number: 52413 ) |
| Policy contract number | ERLV00300339003 |
| Policy instance | 2 |
| Insurance contract or identification number | ERLV00300339003 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-11-30 | | Total amount of fees paid to insurance company | USD $38,064 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes |
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| COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
| Policy contract number | 00137229 |
| Policy instance | 1 |
| Insurance contract or identification number | 00137229 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,448 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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