CONCOURSE HOTEL INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS
401k plan membership statisitcs for CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS
| Measure | Date | Value |
|---|
| 2020: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-08-01 | 154 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-08-01 | 64 |
| Number of retired or separated participants receiving benefits | 2020-08-01 | 6 |
| Total of all active and inactive participants | 2020-08-01 | 70 |
| Total participants | 2020-08-01 | 70 |
| 2019: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-08-01 | 167 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-08-01 | 162 |
| Number of retired or separated participants receiving benefits | 2019-08-01 | 1 |
| Total of all active and inactive participants | 2019-08-01 | 163 |
| Total participants | 2019-08-01 | 163 |
| 2018: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-08-01 | 156 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-08-01 | 167 |
| Number of retired or separated participants receiving benefits | 2018-08-01 | 2 |
| Total of all active and inactive participants | 2018-08-01 | 169 |
| 2017: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-08-01 | 163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-08-01 | 154 |
| Number of retired or separated participants receiving benefits | 2017-08-01 | 1 |
| Total of all active and inactive participants | 2017-08-01 | 155 |
| 2016: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-08-01 | 161 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-08-01 | 233 |
| Total of all active and inactive participants | 2016-08-01 | 233 |
| 2015: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-08-01 | 161 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 161 |
| Total of all active and inactive participants | 2015-08-01 | 161 |
| 2014: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-08-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-08-01 | 154 |
| Total of all active and inactive participants | 2014-08-01 | 154 |
| 2013: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-08-01 | 99 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-08-01 | 123 |
| Total of all active and inactive participants | 2013-08-01 | 123 |
| 2012: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-08-01 | 163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-08-01 | 166 |
| Number of retired or separated participants receiving benefits | 2012-08-01 | 2 |
| Total of all active and inactive participants | 2012-08-01 | 168 |
| 2011: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-08-01 | 168 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-08-01 | 158 |
| Number of retired or separated participants receiving benefits | 2011-08-01 | 1 |
| Total of all active and inactive participants | 2011-08-01 | 159 |
| 2010: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-08-01 | 166 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-08-01 | 171 |
| Number of retired or separated participants receiving benefits | 2010-08-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2010-08-01 | 0 |
| Total of all active and inactive participants | 2010-08-01 | 172 |
| 2009: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-08-01 | 170 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-08-01 | 164 |
| Number of retired or separated participants receiving benefits | 2009-08-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2009-08-01 | 0 |
| Total of all active and inactive participants | 2009-08-01 | 167 |
| Total participants | 2009-08-01 | 0 |
| 2020: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2020 form 5500 responses |
|---|
| 2020-08-01 | Type of plan entity | Single employer plan |
| 2020-08-01 | Submission has been amended | No |
| 2020-08-01 | This submission is the final filing | No |
| 2020-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-08-01 | Plan is a collectively bargained plan | No |
| 2020-08-01 | Plan funding arrangement – Insurance | Yes |
| 2020-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2019 form 5500 responses |
|---|
| 2019-08-01 | Type of plan entity | Single employer plan |
| 2019-08-01 | Submission has been amended | No |
| 2019-08-01 | This submission is the final filing | No |
| 2019-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-08-01 | Plan is a collectively bargained plan | No |
| 2019-08-01 | Plan funding arrangement – Insurance | Yes |
| 2019-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2018 form 5500 responses |
|---|
| 2018-08-01 | Type of plan entity | Single employer plan |
| 2018-08-01 | Submission has been amended | No |
| 2018-08-01 | This submission is the final filing | No |
| 2018-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-08-01 | Plan is a collectively bargained plan | No |
| 2018-08-01 | Plan funding arrangement – Insurance | Yes |
| 2018-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2017 form 5500 responses |
|---|
| 2017-08-01 | Type of plan entity | Single employer plan |
| 2017-08-01 | Submission has been amended | No |
| 2017-08-01 | This submission is the final filing | No |
| 2017-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-08-01 | Plan is a collectively bargained plan | No |
| 2017-08-01 | Plan funding arrangement – Insurance | Yes |
| 2017-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2016 form 5500 responses |
|---|
| 2016-08-01 | Type of plan entity | Single employer plan |
| 2016-08-01 | Submission has been amended | No |
| 2016-08-01 | This submission is the final filing | No |
| 2016-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-08-01 | Plan is a collectively bargained plan | No |
| 2016-08-01 | Plan funding arrangement – Insurance | Yes |
| 2016-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2015 form 5500 responses |
|---|
| 2015-08-01 | Type of plan entity | Single employer plan |
| 2015-08-01 | Submission has been amended | No |
| 2015-08-01 | This submission is the final filing | No |
| 2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-08-01 | Plan is a collectively bargained plan | No |
| 2015-08-01 | Plan funding arrangement – Insurance | Yes |
| 2015-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2014 form 5500 responses |
|---|
| 2014-08-01 | Type of plan entity | Single employer plan |
| 2014-08-01 | Submission has been amended | No |
| 2014-08-01 | This submission is the final filing | No |
| 2014-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-08-01 | Plan is a collectively bargained plan | No |
| 2014-08-01 | Plan funding arrangement – Insurance | Yes |
| 2014-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2013 form 5500 responses |
|---|
| 2013-08-01 | Type of plan entity | Single employer plan |
| 2013-08-01 | Submission has been amended | No |
| 2013-08-01 | This submission is the final filing | No |
| 2013-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-08-01 | Plan is a collectively bargained plan | No |
| 2013-08-01 | Plan funding arrangement – Insurance | Yes |
| 2013-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2012 form 5500 responses |
|---|
| 2012-08-01 | Type of plan entity | Single employer plan |
| 2012-08-01 | Submission has been amended | No |
| 2012-08-01 | This submission is the final filing | No |
| 2012-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-08-01 | Plan is a collectively bargained plan | No |
| 2012-08-01 | Plan funding arrangement – Insurance | Yes |
| 2012-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2011 form 5500 responses |
|---|
| 2011-08-01 | Type of plan entity | Single employer plan |
| 2011-08-01 | Submission has been amended | No |
| 2011-08-01 | This submission is the final filing | No |
| 2011-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-08-01 | Plan is a collectively bargained plan | No |
| 2011-08-01 | Plan funding arrangement – Insurance | Yes |
| 2011-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2010 form 5500 responses |
|---|
| 2010-08-01 | Type of plan entity | Single employer plan |
| 2010-08-01 | Submission has been amended | No |
| 2010-08-01 | This submission is the final filing | No |
| 2010-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-08-01 | Plan is a collectively bargained plan | No |
| 2010-08-01 | Plan funding arrangement – Insurance | Yes |
| 2010-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: CONCOURSE HOTEL INC GROUP HEALTH, LIFE AND STD BENEFITS 2009 form 5500 responses |
|---|
| 2009-08-01 | Type of plan entity | Single employer plan |
| 2009-08-01 | Submission has been amended | No |
| 2009-08-01 | This submission is the final filing | No |
| 2009-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-08-01 | Plan is a collectively bargained plan | No |
| 2009-08-01 | Plan funding arrangement – Insurance | Yes |
| 2009-08-01 | Plan benefit arrangement – Insurance | Yes |
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 08716 00000 |
| Policy instance | 3 |
| Insurance contract or identification number | 08716 00000 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $3,810 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,810 | | Insurance broker organization code? | 3 |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 900003 |
| Policy instance | 2 |
| Insurance contract or identification number | 900003 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $6,983 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $658,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,983 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AQIL |
| Policy instance | 1 |
| Insurance contract or identification number | G000AQIL | | Number of Individuals Covered | 62 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $3,565 | | Total amount of fees paid to insurance company | USD $1,598 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,843 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,565 | | Amount paid for insurance broker fees | 1598 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AQIL |
| Policy instance | 1 |
| Insurance contract or identification number | G000AQIL | | Number of Individuals Covered | 156 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $6,823 | | Total amount of fees paid to insurance company | USD $878 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,841 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,823 | | Amount paid for insurance broker fees | 878 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 900003 |
| Policy instance | 2 |
| Insurance contract or identification number | 900003 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $9,197 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,250,747 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,197 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 08716 00000 |
| Policy instance | 3 |
| Insurance contract or identification number | 08716 00000 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $6,414 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,414 | | Insurance broker organization code? | 3 |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 900003 |
| Policy instance | 1 |
| Insurance contract or identification number | 900003 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $8,870 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,057,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,870 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AQIL |
| Policy instance | 2 |
| Insurance contract or identification number | G000AQIL | | Number of Individuals Covered | 168 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $6,540 | | Total amount of fees paid to insurance company | USD $3,899 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $58,848 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,540 | | Amount paid for insurance broker fees | 3899 | | 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 | 8716 |
| Policy instance | 3 |
| Insurance contract or identification number | 8716 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $5,830 | | 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 $5,830 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AQIL |
| Policy instance | 2 |
| Insurance contract or identification number | G000AQIL | | Number of Individuals Covered | 155 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $6,294 | | Total amount of fees paid to insurance company | USD $3,291 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $67,182 | | 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 | 8716 |
| Policy instance | 3 |
| Insurance contract or identification number | 8716 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $6,199 | | 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 |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 900003 |
| Policy instance | 1 |
| Insurance contract or identification number | 900003 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $8,070 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $876,670 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 670868 |
| Policy instance | 2 |
| Insurance contract or identification number | 670868 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $4,711 | | Total amount of fees paid to insurance company | USD $1,252 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,711 | | Amount paid for insurance broker fees | 1252 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AQIL |
| Policy instance | 1 |
| Insurance contract or identification number | G000AQIL | | Number of Individuals Covered | 155 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $4,899 | | Total amount of fees paid to insurance company | USD $1,524 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $87,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,899 | | Amount paid for insurance broker fees | 1524 | | Additional information about fees paid to insurance broker | SERVICE FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 900003 |
| Policy instance | 3 |
| Insurance contract or identification number | 900003 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $15,897 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $896,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,897 | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AQIL |
| Policy instance | 3 |
| Insurance contract or identification number | G000AQIL | | Number of Individuals Covered | 153 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $4,634 | | Total amount of fees paid to insurance company | USD $1,509 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $45,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,634 | | Amount paid for insurance broker fees | 1509 | | Additional information about fees paid to insurance broker | OTHER FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 900003 |
| Policy instance | 2 |
| Insurance contract or identification number | 900003 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $21,920 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $863,725 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,920 | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 670868 |
| Policy instance | 1 |
| Insurance contract or identification number | 670868 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $5,652 | | Total amount of fees paid to insurance company | USD $417 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,659 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,652 | | Amount paid for insurance broker fees | 417 | | Additional information about fees paid to insurance broker | BONUSES | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 670868 |
| Policy instance | 3 |
| Insurance contract or identification number | 670868 | | Number of Individuals Covered | 74 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $5,064 | | Total amount of fees paid to insurance company | USD $779 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,064 | | Amount paid for insurance broker fees | 779 | | Additional information about fees paid to insurance broker | VOLUME INCENTIVES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 900003 |
| Policy instance | 2 |
| Insurance contract or identification number | 900003 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $7,960 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $318,979 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,960 | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AQIL |
| Policy instance | 1 |
| Insurance contract or identification number | G000AQIL | | Number of Individuals Covered | 123 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $3,920 | | Total amount of fees paid to insurance company | USD $361 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $37,232 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,920 | | Amount paid for insurance broker fees | 361 | | Additional information about fees paid to insurance broker | OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN (National Association of Insurance Commissioners NAIC id number: 95311 ) |
| Policy contract number | 7382000-2075 |
| Policy instance | 4 |
| Insurance contract or identification number | 7382000-2075 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $20,449 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $463,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,449 | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS, INC. |
|
| GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN (National Association of Insurance Commissioners NAIC id number: 95311 ) |
| Policy contract number | 7382000-2075 |
| Policy instance | 1 |
| Insurance contract or identification number | 7382000-2075 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $20,493 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $512,332 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,493 | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS, INC. |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 07802 |
| Policy instance | 2 |
| Insurance contract or identification number | 07802 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $4,214 | | Total amount of fees paid to insurance company | USD $58 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $42,139 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,214 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 58 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEE | | Insurance broker name | AXA ASSISTANCE, USA |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 670868 |
| Policy instance | 3 |
| Insurance contract or identification number | 670868 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $4,901 | | Total amount of fees paid to insurance company | USD $2,304 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,901 | | Amount paid for insurance broker fees | 2304 | | Additional information about fees paid to insurance broker | VOLUME INCENTIVES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 900003 |
| Policy instance | 4 |
| Insurance contract or identification number | 900003 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $6,920 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $267,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,920 | | Insurance broker organization code? | 3 | | Insurance broker name | M3 INSURANCE SOLUTIONS INC |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 00007 |
| Policy instance | 4 |
| Insurance contract or identification number | 00007 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $7,100 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $257,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 07802 |
| Policy instance | 3 |
| Insurance contract or identification number | 07802 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $4,380 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $43,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 670868 |
| Policy instance | 2 |
| Insurance contract or identification number | 670868 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $5,049 | | Total amount of fees paid to insurance company | USD $1,472 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,970 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN (National Association of Insurance Commissioners NAIC id number: 95311 ) |
| Policy contract number | 7382000-2075 |
| Policy instance | 1 |
| Insurance contract or identification number | 7382000-2075 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $21,456 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $536,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH COOPERATIVE OF SOUTH CENTRAL WISCONSIN (National Association of Insurance Commissioners NAIC id number: 95311 ) |
| Policy contract number | 7382000-2075 |
| Policy instance | 1 |
| Insurance contract or identification number | 7382000-2075 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $21,355 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $534,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 00007 |
| Policy instance | 2 |
| Insurance contract or identification number | 00007 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $8,180 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $293,879 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 07802 |
| Policy instance | 3 |
| Insurance contract or identification number | 07802 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $4,361 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $43,035 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 670868 |
| Policy instance | 4 |
| Insurance contract or identification number | 670868 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $5,215 | | Total amount of fees paid to insurance company | USD $1,537 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,149 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
