AMBULATORY MEDICAL PRACTICES MANAGEMENT SERVICES ORGANIZATION, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN
| Measure | Date | Value |
|---|
| 2021: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 36 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 0 |
| 2020: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 46 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 36 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 36 |
| 2019: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 41 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 46 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 46 |
| 2018: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 43 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 41 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 41 |
| 2017: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 43 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 43 |
| 2016: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 71 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 44 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 44 |
| 2015: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 79 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 71 |
| Total of all active and inactive participants | 2015-01-01 | 71 |
| 2014: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 76 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 79 |
| Total of all active and inactive participants | 2014-01-01 | 79 |
| 2013: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 76 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 76 |
| Total of all active and inactive participants | 2013-01-01 | 76 |
| 2012: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 69 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 76 |
| Total of all active and inactive participants | 2012-01-01 | 76 |
| 2011: CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 69 |
| Total of all active and inactive participants | 2011-07-01 | 69 |
| Measure | Date | Value |
|---|
| 2021 : CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2021 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Was this plan covered by a fidelity bond | 2021-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| 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 | 2021-12-31 | No |
| Did the plan have assets held for investment | 2021-12-31 | 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 | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| 2020 : CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2020 401k financial data |
|---|
| Total income from all sources (including contributions) | 2020-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Was this plan covered by a fidelity bond | 2020-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2020-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Did the plan have assets held for investment | 2020-12-31 | 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 | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| 2019 : CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2019 401k financial data |
|---|
| Total income from all sources (including contributions) | 2019-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Was this plan covered by a fidelity bond | 2019-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Did the plan have assets held for investment | 2019-12-31 | 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 | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| 2018 : CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2018 401k financial data |
|---|
| Total income from all sources (including contributions) | 2018-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Was this plan covered by a fidelity bond | 2018-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2018-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Did the plan have assets held for investment | 2018-12-31 | 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 | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| 2017 : CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2017 401k financial data |
|---|
| Total income from all sources (including contributions) | 2017-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Was this plan covered by a fidelity bond | 2017-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2017-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Did the plan have assets held for investment | 2017-12-31 | 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 | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| 2016 : CCW MANAGEMENT CORP PREMIUM CONVERSION PLAN 2016 401k financial data |
|---|
| Total income from all sources (including contributions) | 2016-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Was this plan covered by a fidelity bond | 2016-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2016-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Did the plan have assets held for investment | 2016-12-31 | 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 | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 410154 |
| Policy instance | 5 |
| Insurance contract or identification number | 410154 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,161 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,161 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICESCOMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 223373 |
| Policy instance | 4 |
| Insurance contract or identification number | 223373 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $334 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $334 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVIES | | Insurance broker organization code? | 3 |
|
| FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 ) |
| Policy contract number | 98882151001 |
| Policy instance | 3 |
| Insurance contract or identification number | 98882151001 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $43 | | Total amount of fees paid to insurance company | USD $90 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 90 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $43 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00520243 |
| Policy instance | 2 |
| Insurance contract or identification number | 00520243 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,501 | | Total amount of fees paid to insurance company | USD $1,767 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,501 | | Amount paid for insurance broker fees | 1767 | | Additional information about fees paid to insurance broker | CONTRACT/ADMIN FEES AND SERVICESCONTRACT/ADMIN FEES AND SERVICES | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0303381 |
| Policy instance | 1 |
| Insurance contract or identification number | 0303381 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $10,206 | | Total amount of fees paid to insurance company | USD $4,158 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,206 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 4158 | | Additional information about fees paid to insurance broker | FEES/ADMIN SERVICES3FEES/ADMIN SERVICES |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 000000410154 |
| Policy instance | 4 |
| Insurance contract or identification number | 000000410154 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,408 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,408 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00520243 |
| Policy instance | 3 |
| Insurance contract or identification number | 00520243 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,474 | | Total amount of fees paid to insurance company | USD $1,206 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,474 | | Amount paid for insurance broker fees | 1206 | | Additional information about fees paid to insurance broker | CONTRACT/ADMIN FEES AND SERVICES | | Insurance broker organization code? | 3 |
|
| FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 ) |
| Policy contract number | 9888215 |
| Policy instance | 2 |
| Insurance contract or identification number | 9888215 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $121 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 |
|
| OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | CM23494 |
| Policy instance | 1 |
| Insurance contract or identification number | CM23494 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $12,819 | | Total amount of fees paid to insurance company | USD $5,894 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,819 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 5894 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 000000410154 |
| Policy instance | 4 |
| Insurance contract or identification number | 000000410154 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,675 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,675 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00520243 |
| Policy instance | 3 |
| Insurance contract or identification number | 00520243 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Additional information about fees paid to insurance broker | CONTRACT/ADMIN FEES AND SERVICES | | Insurance broker organization code? | 3 |
|
| FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 ) |
| Policy contract number | 9888215 |
| Policy instance | 2 |
| Insurance contract or identification number | 9888215 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 |
|
| OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | CM23494 |
| Policy instance | 1 |
| Insurance contract or identification number | CM23494 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $11,627 | | Total amount of fees paid to insurance company | USD $4,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,627 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 4769 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00520243 |
| Policy instance | 3 |
| Insurance contract or identification number | 00520243 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,324 | | Total amount of fees paid to insurance company | USD $900 | | Welfare Benefit Premiums Paid to Carrier | USD $23,047 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,324 | | Amount paid for insurance broker fees | 900 | | Additional information about fees paid to insurance broker | CONTRACT/ADMIN FEES AND SERVICES | | Insurance broker organization code? | 3 |
|
| FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 ) |
| Policy contract number | 9888215 |
| Policy instance | 2 |
| Insurance contract or identification number | 9888215 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Welfare Benefit Premiums Paid to Carrier | USD $2,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 |
|
| OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | CM23494 |
| Policy instance | 1 |
| Insurance contract or identification number | CM23494 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $12,199 | | Total amount of fees paid to insurance company | USD $5,048 | | Welfare Benefit Premiums Paid to Carrier | USD $329,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,199 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 5048 |
|
| FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 ) |
| Policy contract number | 9888215 |
| Policy instance | 2 |
| Insurance contract or identification number | 9888215 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $156 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | ADVOCATE LIFE & HEALTH LLC |
|
| OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | CM23494 |
| Policy instance | 1 |
| Insurance contract or identification number | CM23494 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $11,027 | | Total amount of fees paid to insurance company | USD $6,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,893 | | Additional information about fees paid to insurance broker | COMMISSIONS/ADMIN SERVICES | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 6168 | | Insurance broker name | |
|
