LAC COURTE OREILLES BAND OF LAKE SUPERIOR CHIPPE has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN
401k plan membership statisitcs for LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN
| Measure | Date | Value |
|---|
| 2021: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 651 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 852 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 853 |
| 2020: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 640 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 650 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 651 |
| 2019: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 710 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 617 |
| Total of all active and inactive participants | 2019-10-01 | 617 |
| 2018: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 705 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 712 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 2 |
| Total of all active and inactive participants | 2018-10-01 | 714 |
| 2017: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 670 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 703 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 1 |
| Total of all active and inactive participants | 2017-10-01 | 704 |
| 2016: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 664 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 659 |
| Total of all active and inactive participants | 2016-10-01 | 659 |
| 2015: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 679 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 665 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 1 |
| Total of all active and inactive participants | 2015-10-01 | 666 |
| 2014: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 661 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 654 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 2 |
| Total of all active and inactive participants | 2014-10-01 | 656 |
| 2013: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 660 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 660 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 2 |
| Total of all active and inactive participants | 2013-10-01 | 662 |
| 2012: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 657 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 661 |
| Total of all active and inactive participants | 2012-10-01 | 661 |
| 2011: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 520 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 488 |
| Number of retired or separated participants receiving benefits | 2011-10-01 | 0 |
| Total of all active and inactive participants | 2011-10-01 | 488 |
| 2010: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-10-01 | 664 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 630 |
| Number of retired or separated participants receiving benefits | 2010-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-10-01 | 0 |
| Total of all active and inactive participants | 2010-10-01 | 630 |
| 2009: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 658 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 641 |
| Number of retired or separated participants receiving benefits | 2009-10-01 | 3 |
| Total of all active and inactive participants | 2009-10-01 | 644 |
| Total participants | 2009-10-01 | 0 |
| 2007: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-10-01 | 661 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-10-01 | 619 |
| Number of retired or separated participants receiving benefits | 2007-10-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2007-10-01 | 0 |
| Total of all active and inactive participants | 2007-10-01 | 621 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2007-10-01 | 0 |
| Total participants | 2007-10-01 | 621 |
| Number of participants with account balances | 2007-10-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2007-10-01 | 0 |
| 2021: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Submission has been amended | No |
| 2021-10-01 | This submission is the final filing | No |
| 2021-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-10-01 | Plan is a collectively bargained plan | No |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Submission has been amended | No |
| 2020-10-01 | This submission is the final filing | No |
| 2020-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-10-01 | Plan is a collectively bargained plan | No |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Submission has been amended | No |
| 2019-10-01 | This submission is the final filing | No |
| 2019-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-10-01 | Plan is a collectively bargained plan | No |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Submission has been amended | No |
| 2018-10-01 | This submission is the final filing | No |
| 2018-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-10-01 | Plan is a collectively bargained plan | No |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Submission has been amended | No |
| 2017-10-01 | This submission is the final filing | No |
| 2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-10-01 | Plan is a collectively bargained plan | No |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Submission has been amended | No |
| 2016-10-01 | This submission is the final filing | No |
| 2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-10-01 | Plan is a collectively bargained plan | No |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Submission has been amended | No |
| 2013-10-01 | This submission is the final filing | No |
| 2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-10-01 | Plan is a collectively bargained plan | No |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Submission has been amended | No |
| 2012-10-01 | This submission is the final filing | No |
| 2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-10-01 | Plan is a collectively bargained plan | No |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Submission has been amended | No |
| 2011-10-01 | This submission is the final filing | No |
| 2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-10-01 | Plan is a collectively bargained plan | No |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-10-01 | Type of plan entity | Single employer plan |
| 2010-10-01 | Submission has been amended | No |
| 2010-10-01 | This submission is the final filing | No |
| 2010-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-10-01 | Plan is a collectively bargained plan | No |
| 2010-10-01 | Plan funding arrangement – Insurance | Yes |
| 2010-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | Submission has been amended | No |
| 2009-10-01 | This submission is the final filing | No |
| 2009-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-10-01 | Plan is a collectively bargained plan | No |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2007: LAC COURTE OREILLES TRIBAL GOVERNING BOARD EMPLOYEE BENEFIT HEALTH & WELFARE PLAN 2007 form 5500 responses |
|---|
| 2007-10-01 | Type of plan entity | Single employer plan |
| 2007-10-01 | Submission has been amended | No |
| 2007-10-01 | This submission is the final filing | No |
| 2007-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-10-01 | Plan is a collectively bargained plan | No |
| 2007-10-01 | Plan funding arrangement – Insurance | Yes |
| 2007-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2007-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2007-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 02614 |
| Policy instance | 5 |
| Insurance contract or identification number | 02614 | | Number of Individuals Covered | 503 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $11,048 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,048 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602781 |
| Policy instance | 4 |
| Insurance contract or identification number | 602781 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $4,158 | | Total amount of fees paid to insurance company | USD $863 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,158 | | Amount paid for insurance broker fees | 863 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602780 |
| Policy instance | 3 |
| Insurance contract or identification number | 602780 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $8,338 | | Total amount of fees paid to insurance company | USD $1,112 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,471 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,338 | | Amount paid for insurance broker fees | 1112 | | Additional information about fees paid to insurance broker | ADDITONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602779 |
| Policy instance | 2 |
| Insurance contract or identification number | 602779 | | Number of Individuals Covered | 823 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $8,336 | | Total amount of fees paid to insurance company | USD $5,745 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $313,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,336 | | Amount paid for insurance broker fees | 5745 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000009699 |
| Policy instance | 1 |
| Insurance contract or identification number | 0000009699 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,459 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY PRODUCTS BUNDLE | | Welfare Benefit Premiums Paid to Carrier | USD $14,621 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $57 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602780 |
| Policy instance | 1 |
| Insurance contract or identification number | 602780 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $8,436 | | Total amount of fees paid to insurance company | USD $1,125 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,436 | | Amount paid for insurance broker fees | 1125 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602781 |
| Policy instance | 2 |
| Insurance contract or identification number | 602781 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $3,999 | | Total amount of fees paid to insurance company | USD $800 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,766 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,999 | | Amount paid for insurance broker fees | 800 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 02614 |
| Policy instance | 3 |
| Insurance contract or identification number | 02614 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $10,576 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,576 | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000009699 |
| Policy instance | 4 |
| Insurance contract or identification number | 0000009699 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $685 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY PRODUCTS BUNDLE | | Welfare Benefit Premiums Paid to Carrier | USD $9,378 | | 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 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602779 |
| Policy instance | 5 |
| Insurance contract or identification number | 602779 | | Number of Individuals Covered | 637 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $8,434 | | Total amount of fees paid to insurance company | USD $6,136 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $306,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,434 | | Amount paid for insurance broker fees | 6136 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000009699 |
| Policy instance | 5 |
| Insurance contract or identification number | 0000009699 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,989 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY PRODUCTS BUNDLE | | Commission paid to Insurance Broker | USD $49 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602779 |
| Policy instance | 4 |
| Insurance contract or identification number | 602779 | | Number of Individuals Covered | 694 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $8,684 | | Total amount of fees paid to insurance company | USD $7,134 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $356,725 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,684 | | Amount paid for insurance broker fees | 7134 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602780 |
| Policy instance | 3 |
| Insurance contract or identification number | 602780 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $9,177 | | Total amount of fees paid to insurance company | USD $1,224 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,799 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,177 | | Amount paid for insurance broker fees | 1224 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602781 |
| Policy instance | 2 |
| Insurance contract or identification number | 602781 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 02614 |
| Policy instance | 1 |
| Insurance contract or identification number | 02614 | | Number of Individuals Covered | 484 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $11,264 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,264 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 02614 |
| Policy instance | 1 |
| Insurance contract or identification number | 02614 | | Number of Individuals Covered | 467 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $10,285 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,285 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602780 |
| Policy instance | 2 |
| Insurance contract or identification number | 602780 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $9,346 | | Total amount of fees paid to insurance company | USD $1,246 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $61,824 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,346 | | Amount paid for insurance broker fees | 1246 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602781 |
| Policy instance | 3 |
| Insurance contract or identification number | 602781 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $4,320 | | Total amount of fees paid to insurance company | USD $1,003 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,133 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,320 | | Amount paid for insurance broker fees | 1003 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000009699 |
| Policy instance | 4 |
| Insurance contract or identification number | 0000009699 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $2,351 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY PRODUCTS BUNDLE | | Welfare Benefit Premiums Paid to Carrier | USD $24,874 | | Commission paid to Insurance Broker | USD $73 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602779 |
| Policy instance | 5 |
| Insurance contract or identification number | 602779 | | Number of Individuals Covered | 699 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $8,626 | | Total amount of fees paid to insurance company | USD $6,905 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $345,265 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,626 | | Amount paid for insurance broker fees | 6905 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000009699 |
| Policy instance | 5 |
| Insurance contract or identification number | 0000009699 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $2,244 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY PRODUCTS BUNDLE | | Welfare Benefit Premiums Paid to Carrier | USD $25,275 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602779 |
| Policy instance | 4 |
| Insurance contract or identification number | 602779 | | Number of Individuals Covered | 707 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $8,664 | | Total amount of fees paid to insurance company | USD $7,055 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $352,731 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 02614 |
| Policy instance | 2 |
| Insurance contract or identification number | 02614 | | Number of Individuals Covered | 493 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $11,039 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602780 |
| Policy instance | 3 |
| Insurance contract or identification number | 602780 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $8,590 | | Total amount of fees paid to insurance company | USD $1,145 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $57,268 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 602781 |
| Policy instance | 1 |
| Insurance contract or identification number | 602781 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $4,510 | | Total amount of fees paid to insurance company | USD $1,021 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,772 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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