RX SYSTEMS, INC. has sponsored the creation of one or more 401k plans.
Additional information about RX SYSTEMS, INC.
Submission information for form 5500 for 401k plan RX SYSTEMS, INC. GROUP HEALTH PLAN
401k plan membership statisitcs for RX SYSTEMS, INC. GROUP HEALTH PLAN
| Measure | Date | Value |
|---|
| 2022: RX SYSTEMS, INC. GROUP HEALTH PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 227 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 227 |
| Total of all active and inactive participants | 2022-01-01 | 227 |
| 2021: RX SYSTEMS, INC. GROUP HEALTH PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 236 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 220 |
| Total of all active and inactive participants | 2021-01-01 | 220 |
| 2020: RX SYSTEMS, INC. GROUP HEALTH PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 236 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 236 |
| Total of all active and inactive participants | 2020-01-01 | 236 |
| 2019: RX SYSTEMS, INC. GROUP HEALTH PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 236 |
| Total of all active and inactive participants | 2019-01-01 | 236 |
| 2018: RX SYSTEMS, INC. GROUP HEALTH PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 191 |
| Total of all active and inactive participants | 2018-01-01 | 191 |
| 2017: RX SYSTEMS, INC. GROUP HEALTH PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 219 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 183 |
| Total of all active and inactive participants | 2017-01-01 | 183 |
| 2016: RX SYSTEMS, INC. GROUP HEALTH PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 198 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 219 |
| Total of all active and inactive participants | 2016-01-01 | 219 |
| 2015: RX SYSTEMS, INC. GROUP HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 190 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 198 |
| Total of all active and inactive participants | 2015-01-01 | 198 |
| 2013: RX SYSTEMS, INC. GROUP HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 173 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 190 |
| Total of all active and inactive participants | 2013-01-01 | 190 |
| 2011: RX SYSTEMS, INC. GROUP HEALTH PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 179 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 173 |
| Total of all active and inactive participants | 2011-01-01 | 173 |
| 2009: RX SYSTEMS, INC. GROUP HEALTH PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 83 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 161 |
| Total of all active and inactive participants | 2009-01-01 | 161 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00629209 |
| Policy instance | 5 |
| Insurance contract or identification number | 00629209 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $39,864 | | Total amount of fees paid to insurance company | USD $7,976 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $325,111 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,864 | | Amount paid for insurance broker fees | 7976 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK970910 |
| Policy instance | 4 |
| Insurance contract or identification number | OK970910 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $158 | | Total amount of fees paid to insurance company | USD $120 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $158 | | Amount paid for insurance broker fees | 79 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX969479 |
| Policy instance | 3 |
| Insurance contract or identification number | FLX969479 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $1,539 | | Total amount of fees paid to insurance company | USD $1,170 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,163 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,539 | | Amount paid for insurance broker fees | 769 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 011277 |
| Policy instance | 2 |
| Insurance contract or identification number | 011277 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $33,567 | | Total amount of fees paid to insurance company | USD $12,983 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | 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 $229,664 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,567 | | Amount paid for insurance broker fees | 12983 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 1 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,285 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,285 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 1 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $13,142 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,750 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,142 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 2 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,666 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 889211G |
| Policy instance | 3 |
| Insurance contract or identification number | 889211G | | Number of Individuals Covered | 220 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $16,722 | | Total amount of fees paid to insurance company | USD $8,360 | | 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 $167,214 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,722 | | Amount paid for insurance broker fees | 8360 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX969479 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX969479 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $1,118 | | Total amount of fees paid to insurance company | USD $559 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,118 | | Amount paid for insurance broker fees | 559 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK970910 |
| Policy instance | 5 |
| Insurance contract or identification number | OK970910 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $115 | | Total amount of fees paid to insurance company | USD $57 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $115 | | Amount paid for insurance broker fees | 57 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00629209 |
| Policy instance | 6 |
| Insurance contract or identification number | 00629209 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $41,765 | | Total amount of fees paid to insurance company | USD $8,357 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $234,189 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,765 | | Amount paid for insurance broker fees | 8357 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 5 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $8,352 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,352 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 6 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,806 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,806 | | Insurance broker organization code? | 3 |
|
| HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 ) |
| Policy contract number | 00173462 |
| Policy instance | 7 |
| Insurance contract or identification number | 00173462 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $3,636 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,636 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX969479 |
| Policy instance | 8 |
| Insurance contract or identification number | FLX969479 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-03-01 | | Total amount of commissions paid to insurance broker | USD $858 | | Total amount of fees paid to insurance company | USD $429 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $858 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 429 | | Additional information about fees paid to insurance broker | SALES AND SERVICE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK970910 |
| Policy instance | 9 |
| Insurance contract or identification number | OK970910 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-03-01 | | Total amount of commissions paid to insurance broker | USD $88 | | Total amount of fees paid to insurance company | USD $44 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $880 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $88 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 44 | | Additional information about fees paid to insurance broker | SALES AND SERVICE |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 889211G |
| Policy instance | 10 |
| Insurance contract or identification number | 889211G | | Number of Individuals Covered | 245 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $26,365 | | 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 $175,768 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,365 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 4 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 3 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $2,292 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,833 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,292 | | Insurance broker organization code? | 3 |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00173462 |
| Policy instance | 2 |
| Insurance contract or identification number | 00173462 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $150 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $150 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00629209 |
| Policy instance | 1 |
| Insurance contract or identification number | 00629209 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $41,162 | | Total amount of fees paid to insurance company | USD $8,236 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $202,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,162 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 8236 | | Additional information about fees paid to insurance broker | SERVICE/GENERAL AGENT FEES |
|
| HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 ) |
| Policy contract number | 00173462 |
| Policy instance | 1 |
| Insurance contract or identification number | 00173462 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $46,581 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,043,900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,581 | | Insurance broker organization code? | 3 |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00173462 |
| Policy instance | 2 |
| Insurance contract or identification number | 00173462 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $6,583 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,695 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,583 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 3 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $16,409 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,409 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 4 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $3,316 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,094 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,316 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 5 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $8,678 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $77,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,678 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 916862 |
| Policy instance | 6 |
| Insurance contract or identification number | 916862 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $1,739 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,739 | | Insurance broker organization code? | 3 |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00173462 |
| Policy instance | 7 |
| Insurance contract or identification number | 00173462 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $1,064 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,064 |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 00173462 |
| Policy instance | 2 |
| Insurance contract or identification number | 00173462 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $7,593 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,593 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOC INC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5460230 |
| Policy instance | 3 |
| Insurance contract or identification number | 5460230 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $8,169 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,169 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOCIATES INC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5460230 |
| Policy instance | 4 |
| Insurance contract or identification number | 5460230 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $2,457 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,381 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,457 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOC INC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5460230 |
| Policy instance | 5 |
| Insurance contract or identification number | 5460230 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $7,466 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,466 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOC INC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5460230 |
| Policy instance | 6 |
| Insurance contract or identification number | 5460230 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $1,213 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,836 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,213 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOC INC |
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| UNITED DENTAL CARE OF MISSOURI, INC. (National Association of Insurance Commissioners NAIC id number: 47044 ) |
| Policy contract number | 5460230 |
| Policy instance | 7 |
| Insurance contract or identification number | 5460230 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $237 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | DHMO/PREPAID DENTAL | | Welfare Benefit Premiums Paid to Carrier | USD $4,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $237 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOC INC |
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| UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
| Policy contract number | 5460230 |
| Policy instance | 8 |
| Insurance contract or identification number | 5460230 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $808 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | DHMO/PREPAID DENTAL | | Welfare Benefit Premiums Paid to Carrier | USD $3,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $808 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOC INC |
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| HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 ) |
| Policy contract number | 00173462 |
| Policy instance | 1 |
| Insurance contract or identification number | 00173462 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $34,759 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $772,051 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,759 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOC INC |
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