JIM'S FORMAL WEAR LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN
Measure | Date | Value |
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2022: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 291 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 111 |
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 | 111 |
Number of employers contributing to the scheme | 2022-01-01 | 0 |
2021: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 307 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 291 |
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 | 291 |
Number of employers contributing to the scheme | 2021-01-01 | 0 |
2020: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 342 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 307 |
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 | 307 |
Number of employers contributing to the scheme | 2020-01-01 | 0 |
2019: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 219 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 213 |
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 | 213 |
Number of employers contributing to the scheme | 2019-01-01 | 0 |
2018: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-01-01 | 222 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 219 |
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 | 219 |
2017: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-01-01 | 235 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 222 |
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 | 222 |
2016: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-01-01 | 424 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 235 |
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 | 235 |
2015: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-01-01 | 491 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 410 |
Number of retired or separated participants receiving benefits | 2015-01-01 | 1 |
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 | 411 |
2014: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-01-01 | 491 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 411 |
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 | 411 |
2013: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-01-01 | 541 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 490 |
Number of retired or separated participants receiving benefits | 2013-01-01 | 1 |
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 | 491 |
2022: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Plan funding arrangement – Insurance | Yes |
2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-01-01 | Plan benefit arrangement – Insurance | Yes |
2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2021 form 5500 responses |
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2021-01-01 | Type of plan entity | Single employer plan |
2021-01-01 | Plan funding arrangement – Insurance | Yes |
2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-01-01 | Plan benefit arrangement – Insurance | Yes |
2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2020 form 5500 responses |
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2020-01-01 | Type of plan entity | Single employer plan |
2020-01-01 | Plan funding arrangement – Insurance | Yes |
2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-01-01 | Plan benefit arrangement – Insurance | Yes |
2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2019 form 5500 responses |
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2019-01-01 | Type of plan entity | Single employer plan |
2019-01-01 | Plan funding arrangement – Insurance | Yes |
2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-01-01 | Plan benefit arrangement – Insurance | Yes |
2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2018 form 5500 responses |
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2018-01-01 | Type of plan entity | Single employer plan |
2018-01-01 | Submission has been amended | No |
2018-01-01 | This submission is the final filing | No |
2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-01-01 | Plan is a collectively bargained plan | No |
2018-01-01 | Plan funding arrangement – Insurance | Yes |
2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-01-01 | Plan benefit arrangement – Insurance | Yes |
2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2017 form 5500 responses |
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2017-01-01 | Type of plan entity | Single employer plan |
2017-01-01 | Submission has been amended | No |
2017-01-01 | This submission is the final filing | No |
2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-01-01 | Plan is a collectively bargained plan | No |
2017-01-01 | Plan funding arrangement – Insurance | Yes |
2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-01-01 | Plan benefit arrangement – Insurance | Yes |
2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2016: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2016 form 5500 responses |
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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 funding arrangement – General assets of the sponsor | Yes |
2016-01-01 | Plan benefit arrangement – Insurance | Yes |
2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2015 form 5500 responses |
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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 funding arrangement – General assets of the sponsor | Yes |
2015-01-01 | Plan benefit arrangement – Insurance | Yes |
2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2014: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2014 form 5500 responses |
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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 funding arrangement – General assets of the sponsor | Yes |
2014-01-01 | Plan benefit arrangement – Insurance | Yes |
2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: JIM'S FORMAL WEAR LLC CAFETERIA 125 PLAN 2013 form 5500 responses |
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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 |
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
Policy contract number | 12399000 |
Policy instance | 3 |
Insurance contract or identification number | 12399000 | Number of Individuals Covered | 192 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $2,969 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $138,232 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 2969 | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | Insurance broker organization code? | 3 |
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DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
Policy contract number | 20350 |
Policy instance | 2 |
Insurance contract or identification number | 20350 | Number of Individuals Covered | 143 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | 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 | Welfare Benefit Premiums Paid to Carrier | USD $90,826 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 99258011001 |
Policy instance | 1 |
Insurance contract or identification number | 99258011001 | Number of Individuals Covered | 262 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $14,626 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
Policy contract number | 020203 |
Policy instance | 3 |
Insurance contract or identification number | 020203 | Number of Individuals Covered | 291 | 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 $2,086 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $134,870 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 2086 | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | Insurance broker organization code? | 3 |
|
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
Policy contract number | 20350 |
Policy instance | 2 |
Insurance contract or identification number | 20350 | Number of Individuals Covered | 143 | 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 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $78,913 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 99258011001 |
Policy instance | 1 |
Insurance contract or identification number | 99258011001 | Number of Individuals Covered | 262 | 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 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $14,110 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 99258011001 |
Policy instance | 1 |
Insurance contract or identification number | 99258011001 | Number of Individuals Covered | 274 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $15,988 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
Policy contract number | 20350 |
Policy instance | 2 |
Insurance contract or identification number | 20350 | Number of Individuals Covered | 142 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | 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 | Welfare Benefit Premiums Paid to Carrier | USD $92,953 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
Policy contract number | 913065 |
Policy instance | 3 |
Insurance contract or identification number | 913065 | Number of Individuals Covered | 22 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $237 | Other welfare benefits provided | CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $4,729 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 237 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 912977 |
Policy instance | 4 |
Insurance contract or identification number | 912977 | Number of Individuals Covered | 307 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $19,556 | Total amount of fees paid to insurance company | USD $6,593 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $118,775 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,556 | Amount paid for insurance broker fees | 6593 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
Policy contract number | 20350 |
Policy instance | 3 |
Insurance contract or identification number | 20350 | Number of Individuals Covered | 151 | 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 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $93,222 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 875014G/883205G |
Policy instance | 2 |
Insurance contract or identification number | 875014G/883205G | Number of Individuals Covered | 370 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $-2,986 | Total amount of fees paid to insurance company | USD $2,026 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $204,080 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 1519 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 99258011001 |
Policy instance | 1 |
Insurance contract or identification number | 99258011001 | Number of Individuals Covered | 272 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $777 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $15,225 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $777 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | ETB-200022 |
Policy instance | 3 |
Insurance contract or identification number | ETB-200022 | Number of Individuals Covered | 374 | 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 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | 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 $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 $0 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
Policy contract number | 20350 |
Policy instance | 4 |
Insurance contract or identification number | 20350 | Number of Individuals Covered | 154 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $6,833 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $100,961 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,833 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | AA-S08136 |
Policy instance | 5 |
Insurance contract or identification number | AA-S08136 | Number of Individuals Covered | 222 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $735 | Total amount of fees paid to insurance company | USD $66 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $695 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 66 | Additional information about fees paid to insurance broker | ADDICATIONAL COMPENSATION |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 883205G |
Policy instance | 6 |
Insurance contract or identification number | 883205G | Number of Individuals Covered | 227 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,165 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY CRITICAL ILLNESS | 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 $5,785 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,128 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 875014G |
Policy instance | 2 |
Insurance contract or identification number | 875014G | Number of Individuals Covered | 374 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $29,765 | Total amount of fees paid to insurance company | USD $1,084 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $49,463 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $23,826 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 1084 | Additional information about fees paid to insurance broker | BONUS |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 9925801 |
Policy instance | 1 |
Insurance contract or identification number | 9925801 | Number of Individuals Covered | 277 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $2,699 | 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 $18,194 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,479 | Insurance broker organization code? | 3 |
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ADVANCE MEDICAL, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | JIMS01 |
Policy instance | 8 |
Insurance contract or identification number | JIMS01 | Number of Individuals Covered | 237 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EXPERT MEDICAL OPINION | 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 $2,050 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 0000021282 |
Policy instance | 1 |
Insurance contract or identification number | 0000021282 | Number of Individuals Covered | 361 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $13,908 | 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 | 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 $61,404 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,908 | Insurance broker organization code? | 3 | Insurance broker name | VARIOUS - SEE ATTACHMENT |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 9925801 |
Policy instance | 2 |
Insurance contract or identification number | 9925801 | Number of Individuals Covered | 280 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $2,690 | 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 $18,024 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,690 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 875014G |
Policy instance | 3 |
Insurance contract or identification number | 875014G | Number of Individuals Covered | 374 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $21,145 | Total amount of fees paid to insurance company | USD $2,727 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $211,445 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $21,145 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 2727 | Additional information about fees paid to insurance broker | BONUS | Insurance broker name | MERCER HUMAN RESOURCE |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | ETB-200022 |
Policy instance | 4 |
Insurance contract or identification number | ETB-200022 | Number of Individuals Covered | 700 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $143 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | 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 $950 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $143 | Insurance broker organization code? | 3 | Insurance broker name | ASSURED PARTNERS OF MISSOURI LLC |
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HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 6091010 |
Policy instance | 5 |
Insurance contract or identification number | 6091010 | Number of Individuals Covered | 5 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $158 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | LEGAL | 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 $1,584 | 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 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
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MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | MMPC0-008 |
Policy instance | 6 |
Insurance contract or identification number | MMPC0-008 | Number of Individuals Covered | 390 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $567 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $6,084 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $567 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
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DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
Policy contract number | 20350 |
Policy instance | 7 |
Insurance contract or identification number | 20350 | Number of Individuals Covered | 158 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $6,732 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $90,478 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,732 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS LLC |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0868928 |
Policy instance | 1 |
Insurance contract or identification number | 0868928 | Number of Individuals Covered | 316 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $6,223 | 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 $93,559 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,223 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
Policy contract number | 0000021282 |
Policy instance | 2 |
Insurance contract or identification number | 0000021282 | Number of Individuals Covered | 310 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $17,967 | 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 | 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 $49,512 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,967 | Insurance broker organization code? | 3 | Insurance broker name | VARIOUS - SEE ATTACHMENT |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 9925801 |
Policy instance | 3 |
Insurance contract or identification number | 9925801 | Number of Individuals Covered | 288 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | 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? | 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 $18,699 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 875014G |
Policy instance | 4 |
Insurance contract or identification number | 875014G | Number of Individuals Covered | 410 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $9,114 | Total amount of fees paid to insurance company | USD $673 | 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 | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $90,914 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,114 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 673 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker name | MERCER HUMAN RESOURCE |
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HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 6091010 |
Policy instance | 5 |
Insurance contract or identification number | 6091010 | Number of Individuals Covered | 2 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $58 | Total amount of fees paid to insurance company | USD $4 | 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 | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | LEGAL | 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 $540 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $58 | Amount paid for insurance broker fees | 4 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | MMPCO-008 |
Policy instance | 6 |
Insurance contract or identification number | MMPCO-008 | Number of Individuals Covered | 530 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $992 | 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 | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $8,268 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $992 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH AND BENEFITS, LLC |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00410357 |
Policy instance | 2 |
Insurance contract or identification number | 00410357 | Number of Individuals Covered | 411 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $16,585 | Total amount of fees paid to insurance company | USD $9,771 | 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 | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $219,360 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $16,585 | Amount paid for insurance broker fees | 9771 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
Policy contract number | 14662 |
Policy instance | 1 |
Insurance contract or identification number | 14662 | Number of Individuals Covered | 421 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $66,676 | 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 $227,008 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $40,551 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH |
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BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
Policy contract number | P35532, P35533 |
Policy instance | 1 |
Insurance contract or identification number | P35532, P35533 | Number of Individuals Covered | 491 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $70,959 | Total amount of fees paid to insurance company | USD $3,060 | 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 $215,514 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $70,959 | Amount paid for insurance broker fees | 3060 | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00410357 |
Policy instance | 2 |
Insurance contract or identification number | 00410357 | Number of Individuals Covered | 513 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $16,301 | Total amount of fees paid to insurance company | USD $8,780 | 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 | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $219,192 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $16,301 | Amount paid for insurance broker fees | 8780 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | LOCKTON COMPANIES, LLC |
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