HENDERSEN-WEBB INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN
401k plan membership statisitcs for HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN
| 2022: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 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: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: HENDERSEN WEBB HEALTH AND WELFARE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 2KRA |
| Policy instance | 5 |
| Insurance contract or identification number | 2KRA | | Number of Individuals Covered | 290 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $7,099 | | Total amount of fees paid to insurance company | USD $64,466 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,553,934 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,099 | | Amount paid for insurance broker fees | 64466 | | Additional information about fees paid to insurance broker | NEW BUSINESS BONUSPRODUCER SERVICE FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-03-01 | | Total amount of commissions paid to insurance broker | USD $689 | | Total amount of fees paid to insurance company | USD $1,613 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,780 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $689 | | Amount paid for insurance broker fees | 1613 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-03-01 | | Total amount of commissions paid to insurance broker | USD $47 | | Total amount of fees paid to insurance company | USD $110 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47 | | Amount paid for insurance broker fees | 110 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-03-01 | | Total amount of commissions paid to insurance broker | USD $463 | | Total amount of fees paid to insurance company | USD $1,152 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,260 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $463 | | Amount paid for insurance broker fees | 1152 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-03-01 | | Total amount of commissions paid to insurance broker | USD $425 | | Total amount of fees paid to insurance company | USD $1,041 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $425 | | Amount paid for insurance broker fees | 1041 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-03-01 | | Total amount of commissions paid to insurance broker | USD $2,719 | | Total amount of fees paid to insurance company | USD $557 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,719 | | Amount paid for insurance broker fees | 557 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-03-01 | | Total amount of commissions paid to insurance broker | USD $2,978 | | Total amount of fees paid to insurance company | USD $633 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,978 | | Amount paid for insurance broker fees | 633 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-03-01 | | Total amount of commissions paid to insurance broker | USD $4,133 | | Total amount of fees paid to insurance company | USD $854 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $82,668 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,133 | | Amount paid for insurance broker fees | 854 | | Additional information about fees paid to insurance broker | SALES AND SERVICES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-03-01 | | Total amount of commissions paid to insurance broker | USD $284 | | Total amount of fees paid to insurance company | USD $63 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $5,686 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $284 | | Amount paid for insurance broker fees | 63 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 914021 |
| Policy instance | 5 |
| Insurance contract or identification number | 914021 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $16,124 | | Total amount of fees paid to insurance company | USD $83,959 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,706,581 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,040 | | Amount paid for insurance broker fees | 81197 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 228 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-03-01 | | Total amount of commissions paid to insurance broker | USD $3,131 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,624 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,131 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-03-01 | | Total amount of commissions paid to insurance broker | USD $4,544 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $90,878 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,544 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 914021 |
| Policy instance | 5 |
| Insurance contract or identification number | 914021 | | Number of Individuals Covered | 364 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $81,500 | | Total amount of fees paid to insurance company | USD $3,562 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,492,051 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $81,500 | | Amount paid for insurance broker fees | 3562 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 228 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-03-01 | | Total amount of commissions paid to insurance broker | USD $2,824 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,473 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,824 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-03-01 | | Total amount of commissions paid to insurance broker | USD $309 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $6,178 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $309 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-03-01 | | Total amount of commissions paid to insurance broker | USD $2,436 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,436 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 914021 |
| Policy instance | 5 |
| Insurance contract or identification number | 914021 | | Number of Individuals Covered | 376 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $72,392 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,205,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72,392 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-03-01 | | Total amount of commissions paid to insurance broker | USD $4,057 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,057 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-03-01 | | Total amount of commissions paid to insurance broker | USD $270 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $5,409 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $270 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-03-01 | | Total amount of commissions paid to insurance broker | USD $2,830 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,830 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 286 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-03-01 | | Total amount of commissions paid to insurance broker | USD $122 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $6,429 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $122 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-03-01 | | Total amount of commissions paid to insurance broker | USD $914 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,596 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $914 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CAREFIRST BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 47058 ) |
| Policy contract number | 67002/198W |
| Policy instance | 5 |
| Insurance contract or identification number | 67002/198W | | Number of Individuals Covered | 244 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $81,952 | | Total amount of fees paid to insurance company | USD $28,661 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,530,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $81,952 | | Amount paid for insurance broker fees | 28661 | | Additional information about fees paid to insurance broker | CONTRACT FEES AND NON-MONETARY INCENTIVES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-03-01 | | Total amount of commissions paid to insurance broker | USD $1,196 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,196 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 286 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-03-01 | | Total amount of commissions paid to insurance broker | USD $1,292 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,292 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CAREFIRST BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 47058 ) |
| Policy contract number | 67002/198W |
| Policy instance | 5 |
| Insurance contract or identification number | 67002/198W | | Number of Individuals Covered | 246 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $86,590 | | Total amount of fees paid to insurance company | USD $16,570 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,349,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,978 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 101 | | Additional information about fees paid to insurance broker | NON-MONETARY INCENTIVES | | Insurance broker name | MATHER & STROHL ADMINISTRATIVE SERV |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-03-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-03-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $2,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-03-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,366 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-03-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 198W |
| Policy instance | 5 |
| Insurance contract or identification number | 198W | | Number of Individuals Covered | 231 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $66,584 | | Total amount of fees paid to insurance company | USD $17,497 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,130,227 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,584 | | Amount paid for insurance broker fees | 17497 | | Insurance broker organization code? | 3 | | Insurance broker name | HUMAN CAPITAL CONSULTANTS, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,610 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 289 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $6,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 289 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $71,534 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 394 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $5,142 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,586 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 198W |
| Policy instance | 5 |
| Insurance contract or identification number | 198W | | Number of Individuals Covered | 226 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $56,941 | | Total amount of fees paid to insurance company | USD $18,463 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,579,917 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,941 | | Amount paid for insurance broker fees | 18463 | | Insurance broker organization code? | 3 | | Insurance broker name | HUMAN CAPITAL CONSULTANTS, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 358 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $57,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $4,897 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 198W |
| Policy instance | 5 |
| Insurance contract or identification number | 198W | | Number of Individuals Covered | 223 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $62,311 | | Total amount of fees paid to insurance company | USD $7,785 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,976,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $62,311 | | Amount paid for insurance broker fees | 7785 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HUMAN CAPITAL CONSULTANTS, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,114 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,694 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 198W |
| Policy instance | 5 |
| Insurance contract or identification number | 198W | | Number of Individuals Covered | 229 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-28 | | Total amount of commissions paid to insurance broker | USD $49,173 | | Total amount of fees paid to insurance company | USD $4,322 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,639,151 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,173 | | Amount paid for insurance broker fees | 4322 | | Insurance broker organization code? | 3 | | Insurance broker name | HUMAN CAPITAL CONSULTANTS, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,046 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $6,107 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,726 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 1 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,326 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 398 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $5,584 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 198W |
| Policy instance | 5 |
| Insurance contract or identification number | 198W | | Number of Individuals Covered | 229 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-28 | | Total amount of commissions paid to insurance broker | USD $49,173 | | Total amount of fees paid to insurance company | USD $19,044 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,639,151 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3322036 |
| Policy instance | 1 |
| Insurance contract or identification number | 3322036 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2009-11-01 | | Insurance policy end date | 2010-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $61,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960727 |
| Policy instance | 2 |
| Insurance contract or identification number | LK 960727 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2009-11-01 | | Insurance policy end date | 2010-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 750162 |
| Policy instance | 3 |
| Insurance contract or identification number | LK 750162 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2009-11-01 | | Insurance policy end date | 2010-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,320 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX960850 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX960850 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2009-11-01 | | Insurance policy end date | 2010-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $67,301 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 198W |
| Policy instance | 6 |
| Insurance contract or identification number | 198W | | Number of Individuals Covered | 222 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $37,033 | | Total amount of fees paid to insurance company | USD $39,082 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,855,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,033 | | Amount paid for insurance broker fees | 19743 | | Additional information about fees paid to insurance broker | MEDICAL CONTRACTS 231X85.08 19,653 NON-MONETARY | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITMALL |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 960746 |
| Policy instance | 4 |
| Insurance contract or identification number | OK 960746 | | Number of Individuals Covered | 294 | | Insurance policy start date | 2009-11-01 | | Insurance policy end date | 2010-11-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $5,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
