KEOKUK HEALTH SYSTEMS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN
401k plan membership statisitcs for KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 126 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 0 |
| 2021: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 131 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 126 |
| Total of all active and inactive participants | 2021-01-01 | 126 |
| Total participants | 2021-01-01 | 126 |
| 2020: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 140 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 131 |
| Total of all active and inactive participants | 2020-01-01 | 131 |
| 2019: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 184 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 140 |
| Total of all active and inactive participants | 2019-01-01 | 140 |
| 2018: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 184 |
| Total of all active and inactive participants | 2018-01-01 | 184 |
| 2017: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 203 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 191 |
| Total of all active and inactive participants | 2017-01-01 | 191 |
| 2016: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 216 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 203 |
| Total of all active and inactive participants | 2016-01-01 | 203 |
| Total participants | 2016-01-01 | 203 |
| 2015: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 253 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 218 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 218 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-01-01 | 0 |
| Total participants | 2015-01-01 | 218 |
| 2014: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 260 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 253 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 253 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-01-01 | 0 |
| Total participants | 2014-01-01 | 253 |
| 2013: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 341 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 254 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 260 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-01-01 | 0 |
| Total participants | 2013-01-01 | 260 |
| 2012: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 358 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 336 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 5 |
| Total of all active and inactive participants | 2012-01-01 | 341 |
| Total participants | 2012-01-01 | 341 |
| 2011: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 403 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 364 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 3 |
| Total of all active and inactive participants | 2011-01-01 | 367 |
| Total participants | 2011-01-01 | 367 |
| 2009: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 400 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 412 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 5 |
| Total of all active and inactive participants | 2009-01-01 | 417 |
| Total participants | 2009-01-01 | 417 |
| Measure | Date | Value |
|---|
| 2013 : KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $55,652 |
| Total income from all sources (including contributions) | 2013-12-31 | $661,683 |
| Total loss/gain on sale of assets | 2013-12-31 | $0 |
| Total of all expenses incurred | 2013-12-31 | $219,537 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-12-31 | $207,693 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-12-31 | $661,683 |
| Value of total assets at end of year | 2013-12-31 | $-33,369 |
| Value of total assets at beginning of year | 2013-12-31 | $-419,863 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-12-31 | $11,844 |
| Total interest from all sources | 2013-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-12-31 | No |
| Was this plan covered by a fidelity bond | 2013-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2013-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-12-31 | No |
| Contributions received from participants | 2013-12-31 | $148,001 |
| Participant contributions at end of year | 2013-12-31 | $10,439 |
| Participant contributions at beginning of year | 2013-12-31 | $41,662 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-12-31 | $149,520 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-12-31 | $156,707 |
| Liabilities. Value of operating payables at beginning of year | 2013-12-31 | $55,652 |
| Total non interest bearing cash at end of year | 2013-12-31 | $-193,328 |
| Total non interest bearing cash at beginning of year | 2013-12-31 | $-618,232 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Value of net income/loss | 2013-12-31 | $442,146 |
| Value of net assets at end of year (total assets less liabilities) | 2013-12-31 | $-33,369 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-12-31 | $-475,515 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-12-31 | $74,678 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-12-31 | Yes |
| Has the plan failed to provide any benefit when due under the plan | 2013-12-31 | Yes |
| Contributions received in cash from employer | 2013-12-31 | $513,682 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-12-31 | $133,015 |
| Contract administrator fees | 2013-12-31 | $11,844 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2013-12-31 | No |
| Did the plan have assets held for investment | 2013-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-12-31 | Qualified |
| Accountancy firm name | 2013-12-31 | CASEY PETERSON & ASSOCIATES, LTC |
| Accountancy firm EIN | 2013-12-31 | 460403496 |
| 2012 : KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2012 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2012-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $55,652 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-12-31 | $63,021 |
| Total income from all sources (including contributions) | 2012-12-31 | $1,643,666 |
| Total loss/gain on sale of assets | 2012-12-31 | $0 |
| Total of all expenses incurred | 2012-12-31 | $1,329,908 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-12-31 | $1,201,885 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-12-31 | $1,643,666 |
| Value of total assets at end of year | 2012-12-31 | $-419,863 |
| Value of total assets at beginning of year | 2012-12-31 | $-726,252 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-12-31 | $128,023 |
| Total interest from all sources | 2012-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-12-31 | No |
| Was this plan covered by a fidelity bond | 2012-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2012-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-12-31 | No |
| Contributions received from participants | 2012-12-31 | $669,195 |
| Participant contributions at end of year | 2012-12-31 | $41,662 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2012-12-31 | $156,707 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-12-31 | $27,139 |
| Liabilities. Value of operating payables at end of year | 2012-12-31 | $55,652 |
| Liabilities. Value of operating payables at beginning of year | 2012-12-31 | $63,021 |
| Total non interest bearing cash at end of year | 2012-12-31 | $-618,232 |
| Total non interest bearing cash at beginning of year | 2012-12-31 | $-753,391 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Value of net income/loss | 2012-12-31 | $313,758 |
| Value of net assets at end of year (total assets less liabilities) | 2012-12-31 | $-475,515 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-12-31 | $-789,273 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-12-31 | $330,111 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-12-31 | Yes |
| Has the plan failed to provide any benefit when due under the plan | 2012-12-31 | Yes |
| Contributions received in cash from employer | 2012-12-31 | $974,471 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-12-31 | $871,774 |
| Contract administrator fees | 2012-12-31 | $128,023 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2012-12-31 | No |
| Did the plan have assets held for investment | 2012-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-12-31 | Qualified |
| Accountancy firm name | 2012-12-31 | CASEY PETERSON & ASSOCIATES, LTD |
| Accountancy firm EIN | 2012-12-31 | 460403496 |
| 2011 : KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2011 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2011-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $63,021 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $1,125 |
| Total income from all sources (including contributions) | 2011-12-31 | $1,615,379 |
| Total loss/gain on sale of assets | 2011-12-31 | $0 |
| Total of all expenses incurred | 2011-12-31 | $2,341,207 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-12-31 | $2,206,018 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-12-31 | $1,615,379 |
| Value of total assets at end of year | 2011-12-31 | $-726,252 |
| Value of total assets at beginning of year | 2011-12-31 | $-62,320 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-12-31 | $135,189 |
| Total interest from all sources | 2011-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-12-31 | No |
| Was this plan covered by a fidelity bond | 2011-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2011-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Contributions received from participants | 2011-12-31 | $753,914 |
| Participant contributions at beginning of year | 2011-12-31 | $32,078 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-12-31 | $27,139 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-12-31 | $36,302 |
| Liabilities. Value of operating payables at end of year | 2011-12-31 | $63,021 |
| Liabilities. Value of operating payables at beginning of year | 2011-12-31 | $1,125 |
| Total non interest bearing cash at end of year | 2011-12-31 | $-753,391 |
| Total non interest bearing cash at beginning of year | 2011-12-31 | $-130,700 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Value of net income/loss | 2011-12-31 | $-725,828 |
| Value of net assets at end of year (total assets less liabilities) | 2011-12-31 | $-789,273 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-12-31 | $-63,445 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-12-31 | $349,727 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | Yes |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | Yes |
| Contributions received in cash from employer | 2011-12-31 | $861,465 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-12-31 | $1,856,291 |
| Contract administrator fees | 2011-12-31 | $135,189 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2011-12-31 | No |
| Did the plan have assets held for investment | 2011-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-12-31 | Qualified |
| Accountancy firm name | 2011-12-31 | CASEY PETERSON & ASSOCIATES, LTD |
| Accountancy firm EIN | 2011-12-31 | 460403496 |
| 2010 : KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2010 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2010-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $1,125 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $0 |
| Total income from all sources (including contributions) | 2010-12-31 | $264,460 |
| Total loss/gain on sale of assets | 2010-12-31 | $0 |
| Total of all expenses incurred | 2010-12-31 | $327,905 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2010-12-31 | $300,841 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2010-12-31 | $264,460 |
| Value of total assets at end of year | 2010-12-31 | $-62,320 |
| Value of total assets at beginning of year | 2010-12-31 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2010-12-31 | $27,064 |
| Total interest from all sources | 2010-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2010-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2010-12-31 | No |
| Was this plan covered by a fidelity bond | 2010-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2010-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2010-12-31 | No |
| Contributions received from participants | 2010-12-31 | $193,190 |
| Participant contributions at end of year | 2010-12-31 | $32,078 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2010-12-31 | $36,302 |
| Liabilities. Value of operating payables at end of year | 2010-12-31 | $1,125 |
| Total non interest bearing cash at end of year | 2010-12-31 | $-130,700 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Value of net income/loss | 2010-12-31 | $-63,445 |
| Value of net assets at end of year (total assets less liabilities) | 2010-12-31 | $-63,445 |
| Value of net assets at beginning of year (total assets less liabilities) | 2010-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2010-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2010-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2010-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2010-12-31 | $89,659 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2010-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2010-12-31 | Yes |
| Has the plan failed to provide any benefit when due under the plan | 2010-12-31 | No |
| Contributions received in cash from employer | 2010-12-31 | $71,270 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2010-12-31 | $211,182 |
| Contract administrator fees | 2010-12-31 | $27,064 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2010-12-31 | No |
| Did the plan have assets held for investment | 2010-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2010-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2010-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2010-12-31 | Qualified |
| Accountancy firm name | 2010-12-31 | CASEY PETERSON & ASSOCIATES, LTD |
| Accountancy firm EIN | 2010-12-31 | 460403496 |
| 2022: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | This submission is the final filing | Yes |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | Yes |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: KEOKUK HEALTH SYSTEMS HEALTH, DENTAL, LIFE & DISABILITY BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5999643 |
| Policy instance | 2 |
| Insurance contract or identification number | 5999643 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,927 | | Total amount of fees paid to insurance company | USD $17 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $77,403 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,927 | | Amount paid for insurance broker fees | 17 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016761-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016761-00 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $5,660 | | Total amount of fees paid to insurance company | USD $3,882 | | 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 $41,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,660 | | Amount paid for insurance broker fees | 3882 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00055483 |
| Policy instance | 5 |
| Insurance contract or identification number | 00055483 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $1,245,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98771351001 |
| Policy instance | 4 |
| Insurance contract or identification number | 98771351001 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,063 | | 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 | 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 $10,678 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,063 | | Additional information about fees paid to insurance broker | COMMISSION | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $74 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $74 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | STANDARD COMMISSIONS | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5999643 |
| Policy instance | 2 |
| Insurance contract or identification number | 5999643 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,995 | | Total amount of fees paid to insurance company | USD $17 | | 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 $79,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,995 | | Amount paid for insurance broker fees | 17 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016761-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016761-00 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $9,628 | | Total amount of fees paid to insurance company | USD $3,158 | | 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 | | 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 $86,851 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,628 | | Amount paid for insurance broker fees | 3158 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016761-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016761-00 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $10,441 | | Total amount of fees paid to insurance company | USD $4,909 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,441 | | Amount paid for insurance broker fees | 4909 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9877135001 |
| Policy instance | 2 |
| Insurance contract or identification number | 9877135001 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,694 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,356 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-05-01 | | Total amount of commissions paid to insurance broker | USD $9 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60 | | 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 | | Insurance broker organization code? | 3 |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00055483 |
| Policy instance | 4 |
| Insurance contract or identification number | 00055483 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,694 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,094,095 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,356 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5999643 |
| Policy instance | 5 |
| Insurance contract or identification number | 5999643 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,177 | | Total amount of fees paid to insurance company | USD $16 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,316 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,950 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 16 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016761-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016761-00 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $12,330 | | Total amount of fees paid to insurance company | USD $4,352 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $112,920 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,330 | | Amount paid for insurance broker fees | 4352 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9877135001 |
| Policy instance | 2 |
| Insurance contract or identification number | 9877135001 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,189 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,846 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,189 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-05-01 | | Total amount of commissions paid to insurance broker | USD $112 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $112 | | Insurance broker organization code? | 3 |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00055483 |
| Policy instance | 4 |
| Insurance contract or identification number | 00055483 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,266,092 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5999643 |
| Policy instance | 5 |
| Insurance contract or identification number | 5999643 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,029 | | Total amount of fees paid to insurance company | USD $530 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $106,934 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,029 | | Amount paid for insurance broker fees | 530 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016761-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016761-00 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $13,332 | | Total amount of fees paid to insurance company | USD $5,637 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $120,263 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,332 | | Amount paid for insurance broker fees | 5637 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | A0480C02 |
| Policy instance | 2 |
| Insurance contract or identification number | A0480C02 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $105 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $77 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9877135001 |
| Policy instance | 3 |
| Insurance contract or identification number | 9877135001 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,127 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,348 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $754 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 4 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-05-01 | | Total amount of commissions paid to insurance broker | USD $118 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $789 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $118 | | Insurance broker organization code? | 3 |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00055483 |
| Policy instance | 5 |
| Insurance contract or identification number | 00055483 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,186,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5999643 |
| Policy instance | 6 |
| Insurance contract or identification number | 5999643 | | Number of Individuals Covered | 293 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $10,069 | | Total amount of fees paid to insurance company | USD $388 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,775 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,792 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 388 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPSENSATION |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | T05999643 |
| Policy instance | 2 |
| Insurance contract or identification number | T05999643 | | Number of Individuals Covered | 293 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,772 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $67,631 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,386 | | Insurance broker organization code? | 3 | | Insurance broker name | MUTUAL MED INS SERVICES LLC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9877135001 |
| Policy instance | 3 |
| Insurance contract or identification number | 9877135001 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,127 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,209 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $789 | | Insurance broker name | MUTUAL MED INS SERVICES LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 4 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-05-01 | | Total amount of commissions paid to insurance broker | USD $135 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $135 | | Insurance broker organization code? | 3 | | Insurance broker name | TWO RIVERS INSURANCE SERV |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00055483 |
| Policy instance | 5 |
| Insurance contract or identification number | 00055483 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $29 | | Total amount of fees paid to insurance company | USD $37,314 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,240,282 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29 | | Amount paid for insurance broker fees | 37314 | | Additional information about fees paid to insurance broker | BROKER CONSULTANT FEE | | Insurance broker organization code? | 3 | | Insurance broker name | LMC INSURANCE & RISK MANAGEMENT INC |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016761-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-016761-00 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $14,350 | | Total amount of fees paid to insurance company | USD $2,996 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $130,139 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,350 | | Amount paid for insurance broker fees | 2996 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | VHA MID AMERICA INSURANCE SERV |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 5 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-05-01 | | Total amount of commissions paid to insurance broker | USD $170 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $170 | | Insurance broker organization code? | 3 | | Insurance broker name | TWO RIVERS INSURANCE SERV |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00055483 |
| Policy instance | 1 |
| Insurance contract or identification number | 00055483 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $45,657 | | 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 | 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 $1,374,243 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,657 | | Insurance broker organization code? | 3 | | Insurance broker name | LMC INSURANCE & RISK MANAGEMENT INC |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5999643 |
| Policy instance | 2 |
| Insurance contract or identification number | 5999643 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $9,152 | | 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 $127,768 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,775 | | Insurance broker organization code? | 3 | | Insurance broker name | KSB INSURANCE SERVICES LLC |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | A0480C02 |
| Policy instance | 3 |
| Insurance contract or identification number | A0480C02 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $3,863 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $15,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $568 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE SOLUTIONS INC |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-016761-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-016761-00 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $15,183 | | Total amount of fees paid to insurance company | USD $5,819 | | 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 | 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 | | 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 $139,166 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,183 | | Amount paid for insurance broker fees | 5819 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | VHA MID AMERICA INSURANCE SERV |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9877135 |
| Policy instance | 6 |
| Insurance contract or identification number | 9877135 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $1,123 | | 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 | 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 $11,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $337 | | Insurance broker organization code? | 3 | | Insurance broker name | KSB INSURANCE SERVICES, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 136931 |
| Policy instance | 4 |
| Insurance contract or identification number | 136931 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $9,609 | | 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 | 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 | | 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 $109,480 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 815 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $8,794 | | Insurance broker name | MUTUAL MED INC |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 6 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-05-01 | | Total amount of commissions paid to insurance broker | USD $232 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $1,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $232 | | Insurance broker organization code? | 3 | | Insurance broker name | TWO RIVERS INSURANCE SERVICE |
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| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | A0480C02 |
| Policy instance | 3 |
| Insurance contract or identification number | A0480C02 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $3,945 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $21,641 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,120 | | Insurance broker organization code? | 3 | | Insurance broker name | TWO RIVERS INS CO INC |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05999643 |
| Policy instance | 2 |
| Insurance contract or identification number | TS05999643 | | Number of Individuals Covered | 362 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $10,891 | | 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 $143,072 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,065 | | Insurance broker organization code? | 3 | | Insurance broker name | KSB INSURANCE SERVICES LLC |
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| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00055483 |
| Policy instance | 1 |
| Insurance contract or identification number | 00055483 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $49,619 | | 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 | 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 $1,505,883 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,435 | | Insurance broker organization code? | 3 | | Insurance broker name | LMC INSURANCE & RISK MANAGEMENT |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 136932 |
| Policy instance | 5 |
| Insurance contract or identification number | 136932 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $9,472 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $60,139 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 451 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $9,021 | | Insurance broker name | MUTUAL MED INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9877135 |
| Policy instance | 7 |
| Insurance contract or identification number | 9877135 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $1,241 | | 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 | 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 $12,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $372 | | Insurance broker organization code? | 3 | | Insurance broker name | KSB INSURANCE SERVICES, INC |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05999643 |
| Policy instance | 4 |
| Insurance contract or identification number | TS05999643 | | Number of Individuals Covered | 399 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $10,490 | | 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 $149,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,242 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MUTUAL MED INS SERVICES, LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 136931 |
| Policy instance | 2 |
| Insurance contract or identification number | 136931 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $9,293 | | 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 | 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 | | 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 $109,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,968 | | Amount paid for insurance broker fees | 375 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MUTUAL MED INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 6 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-05-01 | | Total amount of commissions paid to insurance broker | USD $339 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $2,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $339 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | TWO RIVERS INSURANCE |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | A0480C02 |
| Policy instance | 5 |
| Insurance contract or identification number | A0480C02 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $4,801 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $23,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,651 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE SOLUTIONSS, INC |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00055483 |
| Policy instance | 1 |
| Insurance contract or identification number | 00055483 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $49,904 | | 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 | 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 $1,472,722 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,223 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | PROFESSIONAL INS PLANNERS & CONSUL |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 136932 |
| Policy instance | 3 |
| Insurance contract or identification number | 136932 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $12,642 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $82,361 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,597 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | TWO RIVERS INSURANCE SERVICES |
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| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | A0480C02 |
| Policy instance | 4 |
| Insurance contract or identification number | A0480C02 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $5,031 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $25,305 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,655 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS L PETSCHE |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 817037 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 817037 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-05-01 | | Total amount of commissions paid to insurance broker | USD $285 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $1,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $285 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | TWO RIVERS INSURANCE SERVICES |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 136931 |
| Policy instance | 2 |
| Insurance contract or identification number | 136931 | | Number of Individuals Covered | 319 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $9,674 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $121,468 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | 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 | No | | Vision 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 | | Commission paid to Insurance Broker | USD $9,674 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | TWO RIVERS INSURANCE SERVICES |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 136932 |
| Policy instance | 1 |
| Insurance contract or identification number | 136932 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-30 | | Total amount of commissions paid to insurance broker | USD $14,604 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $97,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | 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 | No | | Vision 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 | | Commission paid to Insurance Broker | USD $14,604 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | TWO RIVERS INSURANCE SERVICES |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 136932 |
| Policy instance | 2 |
| Insurance contract or identification number | 136932 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $15,277 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $101,918 | | 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 | 136931 |
| Policy instance | 1 |
| Insurance contract or identification number | 136931 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $9,632 | | 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 | 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 | | 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 $139,867 | | 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 | 136931 |
| Policy instance | 4 |
| Insurance contract or identification number | 136931 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $11,714 | | 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 | 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 | | 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 $154,434 | | 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 | 136932 |
| Policy instance | 3 |
| Insurance contract or identification number | 136932 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $11,672 | | 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 | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $75,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| KEOKUK AREA HOSPITAL ORGANIZED DELIVERY SYSTEM (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 78401002 |
| Policy instance | 2 |
| Insurance contract or identification number | 78401002 | | Number of Individuals Covered | 253 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $46,599 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KEOKUK AREA HOSPITAL ORGANIZED DELIVERY SYSTEM (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 78401002 |
| Policy instance | 1 |
| Insurance contract or identification number | 78401002 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $9,428 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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