BURRIS LOGISTICS has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM
401k plan membership statisitcs for BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM
| Measure | Date | Value |
|---|
| 2022: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 1,906 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 1,152 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 90 |
| 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 | 1,242 |
| 2021: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 1,639 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 1,853 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 67 |
| 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 | 1,920 |
| 2020: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 1,643 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 1,575 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 64 |
| 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 | 1,639 |
| 2019: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 1,693 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 1,596 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 47 |
| 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 | 1,643 |
| 2018: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 1,592 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 1,664 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 29 |
| 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 | 1,693 |
| 2017: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 1,788 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 1,568 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 24 |
| 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 | 1,592 |
| 2016: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 1,831 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 1,765 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 23 |
| 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 | 1,788 |
| 2015: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 1,752 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 1,831 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 23 |
| 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 | 1,854 |
| 2014: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 1,711 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 1,729 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 23 |
| 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 | 1,752 |
| 2013: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 1,768 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 1,687 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 24 |
| Total of all active and inactive participants | 2013-01-01 | 1,711 |
| 2012: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 1,587 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 1,768 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 24 |
| Total of all active and inactive participants | 2012-01-01 | 1,792 |
| 2011: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 1,532 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 1,561 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 26 |
| Total of all active and inactive participants | 2011-01-01 | 1,587 |
| Total participants | 2011-01-01 | 1,587 |
| 2009: BURRIS LOGISTICS HEALTH & WELFARE BENEFIT PROGRAM 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 2,717 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 2,568 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 28 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 28 |
| Total of all active and inactive participants | 2009-01-01 | 2,624 |
| Total participants | 2009-01-01 | 2,624 |
| ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 ) |
| Policy contract number | GTU-6304917 |
| Policy instance | 4 |
| Insurance contract or identification number | GTU-6304917 | | Number of Individuals Covered | 1152 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $135 | | 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 (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 $900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $135 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMDC0AEEK |
| Policy instance | 3 |
| Insurance contract or identification number | GMDC0AEEK | | Number of Individuals Covered | 428 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,752 | | Total amount of fees paid to insurance company | USD $2,827 | | 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 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 $31,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,752 | | Amount paid for insurance broker fees | 2827 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AEEK |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0AEEK | | Number of Individuals Covered | 1152 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $49,916 | | Total amount of fees paid to insurance company | USD $93,143 | | 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 & 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 $1,080,987 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,916 | | Amount paid for insurance broker fees | 58298 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 ET AL |
| Policy instance | 1 |
| Insurance contract or identification number | 9766338 ET AL | | Number of Individuals Covered | 1443 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $17,943 | | 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 $128,541 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,187 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 3 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2509 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $36,296 | | 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 $153,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,671 | | Insurance broker organization code? | 3 |
|
| ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 ) |
| Policy contract number | GTU-6304917 |
| Policy instance | 2 |
| Insurance contract or identification number | GTU-6304917 | | Number of Individuals Covered | 1853 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $135 | | 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 $900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $135 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 1 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 1853 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $72,588 | | Total amount of fees paid to insurance company | USD $34,845 | | 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 & 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 $1,679,542 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72,588 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 34845 | | Additional information about fees paid to insurance broker | ADMINISTRATION |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 3 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2841 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $15,192 | | 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 $143,471 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,443 | | Insurance broker organization code? | 3 |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA 10505 |
| Policy instance | 2 |
| Insurance contract or identification number | BTA 10505 | | Number of Individuals Covered | 1575 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $216 | | 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 $1,440 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $216 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 1 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 2059 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $74,417 | | Total amount of fees paid to insurance company | USD $66,759 | | 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 & DISMEMBERMENT AND 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 $1,713,062 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,464 | | Amount paid for insurance broker fees | 66759 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 3 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2261 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $13,490 | | 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 $147,261 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,490 | | Insurance broker organization code? | 3 |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA-10505 |
| Policy instance | 4 |
| Insurance contract or identification number | BTA-10505 | | Number of Individuals Covered | 1596 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $216 | | 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 $1,440 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $216 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0514737 |
| Policy instance | 2 |
| Insurance contract or identification number | R0514737 | | Number of Individuals Covered | 1197 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $46,492 | | Total amount of fees paid to insurance company | USD $1,575 | | 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 | ACCIDENT AND 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 $301,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,952 | | Amount paid for insurance broker fees | 859 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 1 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 1596 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $56,111 | | Total amount of fees paid to insurance company | USD $60,190 | | 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 & DISMEMBERMENT AND 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 $1,344,792 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,111 | | Amount paid for insurance broker fees | 60190 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | BLG BG001 |
| Policy instance | 7 |
| Insurance contract or identification number | BLG BG001 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,842 | | Total amount of fees paid to insurance company | USD $4,639 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $18,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,842 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2242 | | Insurance broker name | NEW BENEFITS, LTC |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 71536 |
| Policy instance | 5 |
| Insurance contract or identification number | 71536 | | Number of Individuals Covered | 2413 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $36,849 | | Total amount of fees paid to insurance company | USD $99,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,849 | | Amount paid for insurance broker fees | 99445 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | J.S. CLARK AGENCY, INC |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA-10505 |
| Policy instance | 1 |
| Insurance contract or identification number | BTA-10505 | | Number of Individuals Covered | 1506 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $196 | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $196 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 4 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2118 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $14,305 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $152,188 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,305 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 12151546 |
| Policy instance | 6 |
| Insurance contract or identification number | 12151546 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $220 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $220 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | DAVID HERNANDEZ FINANCIAL SERVICES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97858901001 |
| Policy instance | 8 |
| Insurance contract or identification number | 97858901001 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $123 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,230 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $123 | | Additional information about fees paid to insurance broker | AGENT OR BROKER ON RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | J S CLARK AGENCY |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0514737 |
| Policy instance | 3 |
| Insurance contract or identification number | R0514737 | | Number of Individuals Covered | 1593 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $66,865 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $375,620 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,268 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | SMITH, THOMAS, CHRISTOPHER |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 2 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 1568 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $49,136 | | Total amount of fees paid to insurance company | USD $62,233 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,204,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,136 | | Amount paid for insurance broker fees | 62233 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA-10505 |
| Policy instance | 1 |
| Insurance contract or identification number | BTA-10505 | | Number of Individuals Covered | 1621 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $214 | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785890 |
| Policy instance | 8 |
| Insurance contract or identification number | 9785890 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $9 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87 | | 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 | | Additional information about fees paid to insurance broker | AGENT OR BROKER ON RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | J S CLARK AGENCY |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | BLG BG001 |
| Policy instance | 7 |
| Insurance contract or identification number | BLG BG001 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,990 | | Total amount of fees paid to insurance company | USD $9,557 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $40,535 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 445 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Commission paid to Insurance Broker | USD $5,990 | | Insurance broker organization code? | 3 | | Insurance broker name | MITCH BESVINIK/ INNOBENEFITS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 12151546 |
| Policy instance | 6 |
| Insurance contract or identification number | 12151546 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $294 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,937 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $294 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | DAVID HERNANDEZ FINANCIAL SERVICES |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 71536 |
| Policy instance | 5 |
| Insurance contract or identification number | 71536 | | Number of Individuals Covered | 2906 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $137,672 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $137,672 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | J.S. CLARK AGENCY, INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0514737 |
| Policy instance | 3 |
| Insurance contract or identification number | R0514737 | | Number of Individuals Covered | 1482 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $99,925 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $409,774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69,953 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 2 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 1831 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $51,563 | | Total amount of fees paid to insurance company | USD $61,923 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,283,706 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,563 | | Amount paid for insurance broker fees | 61923 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 4 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2468 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $15,183 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $141,118 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,183 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 52421 ) |
| Policy contract number | BLG BG001 |
| Policy instance | 7 |
| Insurance contract or identification number | BLG BG001 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $5,848 | | Total amount of fees paid to insurance company | USD $9,136 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $39,621 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 428 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Commission paid to Insurance Broker | USD $5,848 | | Insurance broker name | MITCH BESVINIK/ INNOBENEFITS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 12151546 |
| Policy instance | 6 |
| Insurance contract or identification number | 12151546 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $284 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,838 | | 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 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | DAVID HERNANDEZ FINANCIAL SERVICES |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 71536 |
| Policy instance | 5 |
| Insurance contract or identification number | 71536 | | Number of Individuals Covered | 2887 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $140,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $140,778 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | J.S. CLARK AGENCY, INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0514737 |
| Policy instance | 3 |
| Insurance contract or identification number | R0514737 | | Number of Individuals Covered | 1407 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $285,904 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $426,405 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $200,115 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker name | |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 2 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 1729 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $49,736 | | Total amount of fees paid to insurance company | USD $48,199 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,245,583 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,736 | | Amount paid for insurance broker fees | 48199 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA-10505 |
| Policy instance | 1 |
| Insurance contract or identification number | BTA-10505 | | Number of Individuals Covered | 1621 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $214 | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 4 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2331 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $13,474 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,954 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,474 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 4 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2298 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $15,661 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $143,383 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,661 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 ) |
| Policy contract number | 12151546 |
| Policy instance | 7 |
| Insurance contract or identification number | 12151546 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $285 | | Welfare Benefit Premiums Paid to Carrier | USD $2,852 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $285 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | DAVID HERNANDEZ FINANCIAL SERVICES |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 71536 |
| Policy instance | 6 |
| Insurance contract or identification number | 71536 | | Number of Individuals Covered | 2825 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $125,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $125,375 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | J.S. CLARK AGENCY, INC |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | ST-0100-2581 |
| Policy instance | 3 |
| Insurance contract or identification number | ST-0100-2581 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $13,550 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $135,499 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,550 | | Additional information about fees paid to insurance broker | ADMIN AND CLAIM PAYMENT FEES | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785890 |
| Policy instance | 5 |
| Insurance contract or identification number | 9785890 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $35 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $311 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | J S CLARK AGENCY - BOR |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA-10505 |
| Policy instance | 1 |
| Insurance contract or identification number | BTA-10505 | | Number of Individuals Covered | 1621 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $214 | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 2 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 1687 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $80,823 | | Total amount of fees paid to insurance company | USD $43,392 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,166,522 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,591 | | Amount paid for insurance broker fees | 43392 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker name | ROY LAMPHIER |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 2 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 1768 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $77,031 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,077,127 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,554 | | Additional information about fees paid to insurance broker | AGENT OR BROKER RECORD | | Insurance broker name | ROY LAMPHIER |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 71536 |
| Policy instance | 6 |
| Insurance contract or identification number | 71536 | | Number of Individuals Covered | 2864 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $95,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $95,760 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | J.S. CLARK AGENCY, INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785890 |
| Policy instance | 5 |
| Insurance contract or identification number | 9785890 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $52 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $487 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | J S CLARK AGENCY - BOR |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 4 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2225 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $13,248 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $135,774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,248 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | ST-0100-2581 |
| Policy instance | 3 |
| Insurance contract or identification number | ST-0100-2581 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $14,508 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $145,081 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,508 | | Additional information about fees paid to insurance broker | ADMIN AND CLAIM PAYMENT FEES | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA-10505 |
| Policy instance | 1 |
| Insurance contract or identification number | BTA-10505 | | Number of Individuals Covered | 1621 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $214 | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,426 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | J. S. CLARK AGENCY, INC. |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 71536 |
| Policy instance | 8 |
| Insurance contract or identification number | 71536 | | Number of Individuals Covered | 2748 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $46,390 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 4 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 2201 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $31,086 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | A D & D | | Welfare Benefit Premiums Paid to Carrier | USD $267,871 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 ) |
| Policy contract number | 113377-187 |
| Policy instance | 10 |
| Insurance contract or identification number | 113377-187 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-12-31 | | 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 | ST-0100-2581 |
| Policy instance | 5 |
| Insurance contract or identification number | ST-0100-2581 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $10,030 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $100,302 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 6 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 2084 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $12,991 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $139,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9785890 |
| Policy instance | 7 |
| Insurance contract or identification number | 9785890 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $67 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 ) |
| Policy contract number | 113277 |
| Policy instance | 1 |
| Insurance contract or identification number | 113277 | | Number of Individuals Covered | 2104 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $36,891 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $164,128 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0104687 |
| Policy instance | 2 |
| Insurance contract or identification number | 0104687 | | Number of Individuals Covered | 1107 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $31,361 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $431,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA-10505 |
| Policy instance | 3 |
| Insurance contract or identification number | BTA-10505 | | Number of Individuals Covered | 1621 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $213 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 ) |
| Policy contract number | 113277 |
| Policy instance | 9 |
| Insurance contract or identification number | 113277 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-12-31 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9766338 |
| Policy instance | 6 |
| Insurance contract or identification number | 9766338 | | Number of Individuals Covered | 1891 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $9,772 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,772 | | Insurance broker name | J.S. CLARK AGENCY, INC. |
|
| BLUE CROSS BLUE SHIELD OF DELAWARE, INC. (National Association of Insurance Commissioners NAIC id number: 53287 ) |
| Policy contract number | 113277 |
| Policy instance | 1 |
| Insurance contract or identification number | 113277 | | Number of Individuals Covered | 2386 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $74,725 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $286,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $74,725 | | Insurance broker name | J.S. CLARK AGENCY, INC. |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | ST-0100-2581 |
| Policy instance | 5 |
| Insurance contract or identification number | ST-0100-2581 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $11,470 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $114,697 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,470 | | Insurance broker name | J.S. CLARK AGENCY, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AEEK |
| Policy instance | 4 |
| Insurance contract or identification number | G000AEEK | | Number of Individuals Covered | 2148 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $16,378 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $246,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,378 | | Insurance broker name | J.S. CLARK AGENCY, INC. |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | BTA-10505 |
| Policy instance | 3 |
| Insurance contract or identification number | BTA-10505 | | Number of Individuals Covered | 1621 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $213 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $1,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $213 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | J.S. CLARK AGENCY, INC. |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0104687 |
| Policy instance | 2 |
| Insurance contract or identification number | 0104687 | | Number of Individuals Covered | 1223 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $21,684 | | Total amount of fees paid to insurance company | USD $1,340 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $306,345 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,684 | | Amount paid for insurance broker fees | 1340 | | Insurance broker name | J.S. CLARK AGENCY, INC. |
|
