LUSA ASSOCIATES, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LUSA ASSOCIATES, INC. & ULTIMA SERVICES CORPORATION EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for LUSA ASSOCIATES, INC. & ULTIMA SERVICES CORPORATION EMPLOYEE BENEFIT PLAN
Measure | Date | Value |
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2021 : LUSA ASSOCIATES, INC. & ULTIMA SERVICES CORPORATION EMPLOYEE BENEFIT PLAN 2021 401k financial data |
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Total unrealized appreciation/depreciation of assets | 2021-12-31 | $0 |
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $399,073 |
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $704,574 |
Total income from all sources (including contributions) | 2021-12-31 | $730,727 |
Total loss/gain on sale of assets | 2021-12-31 | $0 |
Total of all expenses incurred | 2021-12-31 | $802,492 |
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $615,889 |
Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $730,727 |
Value of total assets at end of year | 2021-12-31 | $626,717 |
Value of total assets at beginning of year | 2021-12-31 | $1,003,983 |
Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $186,603 |
Total interest from all sources | 2021-12-31 | $0 |
Total dividends received (eg from common stock, registered investment company shares) | 2021-12-31 | $0 |
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
Administrative expenses professional fees incurred | 2021-12-31 | $23,677 |
Was this plan covered by a fidelity bond | 2021-12-31 | Yes |
Value of fidelity bond cover | 2021-12-31 | $100,000 |
If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2021-12-31 | $261,313 |
Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-12-31 | $23,958 |
Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-12-31 | $31,407 |
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2021-12-31 | $338,330 |
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2021-12-31 | $555,484 |
Administrative expenses (other) incurred | 2021-12-31 | $414 |
Liabilities. Value of operating payables at end of year | 2021-12-31 | $16,677 |
Liabilities. Value of operating payables at beginning of year | 2021-12-31 | $75,154 |
Total non interest bearing cash at end of year | 2021-12-31 | $602,759 |
Total non interest bearing cash at beginning of year | 2021-12-31 | $972,576 |
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
Value of net income/loss | 2021-12-31 | $-71,765 |
Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $227,644 |
Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $299,409 |
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
Investment advisory and management fees | 2021-12-31 | $7,307 |
Expenses. Payments to insurance carriers foe the provision of benefits | 2021-12-31 | $272,421 |
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
Contributions received in cash from employer | 2021-12-31 | $730,727 |
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-12-31 | $82,155 |
Contract administrator fees | 2021-12-31 | $155,205 |
Liabilities. Value of benefit claims payable at end of year | 2021-12-31 | $44,066 |
Liabilities. Value of benefit claims payable at beginning of year | 2021-12-31 | $73,936 |
Did the plan have assets held for investment | 2021-12-31 | No |
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Unqualified |
Accountancy firm name | 2021-12-31 | CLIFTONLARSONALLEN LLP |
Accountancy firm EIN | 2021-12-31 | 410746749 |
2020 : LUSA ASSOCIATES, INC. & ULTIMA SERVICES CORPORATION EMPLOYEE BENEFIT PLAN 2020 401k financial data |
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Total unrealized appreciation/depreciation of assets | 2020-12-31 | $0 |
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $704,574 |
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $551,798 |
Total income from all sources (including contributions) | 2020-12-31 | $1,044,634 |
Total loss/gain on sale of assets | 2020-12-31 | $0 |
Total of all expenses incurred | 2020-12-31 | $1,090,923 |
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $859,101 |
Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $1,044,634 |
Value of total assets at end of year | 2020-12-31 | $1,003,983 |
Value of total assets at beginning of year | 2020-12-31 | $897,496 |
Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $231,822 |
Total interest from all sources | 2020-12-31 | $0 |
Total dividends received (eg from common stock, registered investment company shares) | 2020-12-31 | $0 |
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
Administrative expenses professional fees incurred | 2020-12-31 | $21,000 |
Was this plan covered by a fidelity bond | 2020-12-31 | Yes |
Value of fidelity bond cover | 2020-12-31 | $100,000 |
If this is an individual account plan, was there a blackout period | 2020-12-31 | No |
Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
Participant contributions at end of year | 2020-12-31 | $31,407 |
Participant contributions at beginning of year | 2020-12-31 | $23,630 |
Income. Received or receivable in cash from other sources (including rollovers) | 2020-12-31 | $5,131 |
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2020-12-31 | $340,419 |
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2020-12-31 | $555,484 |
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2020-12-31 | $432,844 |
Administrative expenses (other) incurred | 2020-12-31 | $71,072 |
Liabilities. Value of operating payables at end of year | 2020-12-31 | $75,154 |
Liabilities. Value of operating payables at beginning of year | 2020-12-31 | $68,471 |
Total non interest bearing cash at end of year | 2020-12-31 | $972,576 |
Total non interest bearing cash at beginning of year | 2020-12-31 | $873,866 |
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
Value of net income/loss | 2020-12-31 | $-46,289 |
Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $299,409 |
Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $345,698 |
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $368,443 |
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | No |
Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
Contributions received in cash from employer | 2020-12-31 | $1,039,503 |
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-12-31 | $150,239 |
Contract administrator fees | 2020-12-31 | $139,750 |
Liabilities. Value of benefit claims payable at end of year | 2020-12-31 | $73,936 |
Liabilities. Value of benefit claims payable at beginning of year | 2020-12-31 | $50,483 |
Did the plan have assets held for investment | 2020-12-31 | No |
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
Opinion of an independent qualified public accountant for this plan | 2020-12-31 | Unqualified |
Accountancy firm name | 2020-12-31 | CLIFTONLARSONALLEN LLP |
Accountancy firm EIN | 2020-12-31 | 410746749 |
2019 : LUSA ASSOCIATES, INC. & ULTIMA SERVICES CORPORATION EMPLOYEE BENEFIT PLAN 2019 401k financial data |
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Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $551,798 |
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $525,681 |
Total income from all sources (including contributions) | 2019-12-31 | $1,759,923 |
Total loss/gain on sale of assets | 2019-12-31 | $0 |
Total of all expenses incurred | 2019-12-31 | $1,755,394 |
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $1,419,284 |
Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $1,759,923 |
Value of total assets at end of year | 2019-12-31 | $897,496 |
Value of total assets at beginning of year | 2019-12-31 | $866,850 |
Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $336,110 |
Total interest from all sources | 2019-12-31 | $0 |
Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $0 |
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
Administrative expenses professional fees incurred | 2019-12-31 | $18,468 |
Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
Value of fidelity bond cover | 2019-12-31 | $100,000 |
If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
Participant contributions at end of year | 2019-12-31 | $23,630 |
Participant contributions at beginning of year | 2019-12-31 | $70 |
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2019-12-31 | $502,832 |
Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $0 |
Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $71,870 |
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2019-12-31 | $467,418 |
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2019-12-31 | $237,515 |
Administrative expenses (other) incurred | 2019-12-31 | $102,822 |
Liabilities. Value of operating payables at end of year | 2019-12-31 | $4,968 |
Liabilities. Value of operating payables at beginning of year | 2019-12-31 | $226,220 |
Total non interest bearing cash at end of year | 2019-12-31 | $873,866 |
Total non interest bearing cash at beginning of year | 2019-12-31 | $10,041 |
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
Income. Non cash contributions | 2019-12-31 | $11,888 |
Value of net income/loss | 2019-12-31 | $4,529 |
Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $345,698 |
Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $341,169 |
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $558,958 |
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
Contributions received in cash from employer | 2019-12-31 | $1,748,035 |
Employer contributions (assets) at end of year | 2019-12-31 | $0 |
Employer contributions (assets) at beginning of year | 2019-12-31 | $784,869 |
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-12-31 | $357,494 |
Contract administrator fees | 2019-12-31 | $214,820 |
Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $79,412 |
Liabilities. Value of benefit claims payable at beginning of year | 2019-12-31 | $61,946 |
Did the plan have assets held for investment | 2019-12-31 | No |
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | No |
Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Unqualified |
Accountancy firm name | 2019-12-31 | CLIFTONLARSONALLEN LLP |
Accountancy firm EIN | 2019-12-31 | 410746749 |
2018 : LUSA ASSOCIATES, INC. & ULTIMA SERVICES CORPORATION EMPLOYEE BENEFIT PLAN 2018 401k financial data |
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Total unrealized appreciation/depreciation of assets | 2018-12-31 | $0 |
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $525,681 |
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $229,278 |
Total income from all sources (including contributions) | 2018-12-31 | $3,154,522 |
Total loss/gain on sale of assets | 2018-12-31 | $0 |
Total of all expenses incurred | 2018-12-31 | $3,010,131 |
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $2,351,545 |
Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $3,154,522 |
Value of total assets at end of year | 2018-12-31 | $866,850 |
Value of total assets at beginning of year | 2018-12-31 | $426,056 |
Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $658,586 |
Total interest from all sources | 2018-12-31 | $0 |
Total dividends received (eg from common stock, registered investment company shares) | 2018-12-31 | $0 |
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
Was this plan covered by a fidelity bond | 2018-12-31 | Yes |
Value of fidelity bond cover | 2018-12-31 | $100,000 |
If this is an individual account plan, was there a blackout period | 2018-12-31 | No |
Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
Participant contributions at end of year | 2018-12-31 | $70 |
Participant contributions at beginning of year | 2018-12-31 | $0 |
Income. Received or receivable in cash from other sources (including rollovers) | 2018-12-31 | $13,012 |
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2018-12-31 | $701,386 |
Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-12-31 | $71,870 |
Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-12-31 | $0 |
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2018-12-31 | $237,515 |
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2018-12-31 | $124,019 |
Administrative expenses (other) incurred | 2018-12-31 | $208,830 |
Liabilities. Value of operating payables at end of year | 2018-12-31 | $226,220 |
Liabilities. Value of operating payables at beginning of year | 2018-12-31 | $90,648 |
Total non interest bearing cash at end of year | 2018-12-31 | $10,041 |
Total non interest bearing cash at beginning of year | 2018-12-31 | $153,696 |
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
Value of net income/loss | 2018-12-31 | $144,391 |
Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $341,169 |
Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $196,778 |
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
Expenses. Payments to insurance carriers foe the provision of benefits | 2018-12-31 | $1,007,125 |
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | No |
Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
Contributions received in cash from employer | 2018-12-31 | $3,141,510 |
Employer contributions (assets) at end of year | 2018-12-31 | $784,869 |
Employer contributions (assets) at beginning of year | 2018-12-31 | $272,360 |
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-12-31 | $643,034 |
Contract administrator fees | 2018-12-31 | $449,756 |
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-12-31 | No |
Liabilities. Value of benefit claims payable at end of year | 2018-12-31 | $61,946 |
Liabilities. Value of benefit claims payable at beginning of year | 2018-12-31 | $14,611 |
Did the plan have assets held for investment | 2018-12-31 | No |
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-12-31 | No |
Opinion of an independent qualified public accountant for this plan | 2018-12-31 | Unqualified |
Accountancy firm name | 2018-12-31 | CLIFTONLARSONALLEN LLP |
Accountancy firm EIN | 2018-12-31 | 410746749 |
TELADOC, INC. (National Association of Insurance Commissioners NAIC id number: 62199 ) |
Policy contract number | 238207 |
Policy instance | 8 |
Insurance contract or identification number | 238207 | Number of Individuals Covered | 40 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | TELEHEALTH | 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 $1,461 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL 157947 |
Policy instance | 1 |
Insurance contract or identification number | GL 157947 | Number of Individuals Covered | 106 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $970 | Total amount of fees paid to insurance company | USD $1,144 | 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 | 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 $8,820 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $970 | Amount paid for insurance broker fees | 1144 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | Insurance broker organization code? | 3 |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | VAR 207562 |
Policy instance | 2 |
Insurance contract or identification number | VAR 207562 | Number of Individuals Covered | 106 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $159 | Total amount of fees paid to insurance company | USD $185 | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,446 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $159 | Amount paid for insurance broker fees | 185 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | Insurance broker organization code? | 3 |
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MAGELLAN HEALTHCARE INC. (National Association of Insurance Commissioners NAIC id number: 54199 ) |
Policy contract number | FCE0-001 |
Policy instance | 3 |
Insurance contract or identification number | FCE0-001 | Number of Individuals Covered | 52 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | 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 $982 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 11273-46 |
Policy instance | 4 |
Insurance contract or identification number | 11273-46 | Number of Individuals Covered | 5 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $836 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,572 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 556 | Additional information about fees paid to insurance broker | ADMINISTRATIVE EXPENSES | Insurance broker organization code? | 3 |
|
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | EL117-13505 |
Policy instance | 5 |
Insurance contract or identification number | EL117-13505 | Number of Individuals Covered | 39 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $11,052 | 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 | 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 $221,050 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,052 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | BASE COMMISSIONS | Insurance broker organization code? | 3 |
|
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | AC-32/LM-169 |
Policy instance | 6 |
Insurance contract or identification number | AC-32/LM-169 | Number of Individuals Covered | 38 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,413 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | LIMITED 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 $22,950 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,413 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | BASE COMMISSIONS | Insurance broker organization code? | 3 |
|
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10303631001 |
Policy instance | 7 |
Insurance contract or identification number | 10303631001 | Number of Individuals Covered | 94 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $679 | 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 $6,622 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $679 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | BASE COMMISSIONS | Insurance broker organization code? | 3 |
|
EYE MED VISION CARE (National Association of Insurance Commissioners NAIC id number: 98512 ) |
Policy contract number | CL VIS LAI 2 |
Policy instance | 4 |
Insurance contract or identification number | CL VIS LAI 2 | Number of Individuals Covered | 105 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $238 | 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 $9,529 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $238 | Insurance broker organization code? | 3 |
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MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | FCE0-001 |
Policy instance | 5 |
Insurance contract or identification number | FCE0-001 | Number of Individuals Covered | 110 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | 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 $1,476 | 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 | 11273-46 |
Policy instance | 6 |
Insurance contract or identification number | 11273-46 | Number of Individuals Covered | 6 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
Policy contract number | 09135 |
Policy instance | 7 |
Insurance contract or identification number | 09135 | Number of Individuals Covered | 90 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $13,860 | 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 | 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 $277,204 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,860 | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | EI117-13505 |
Policy instance | 8 |
Insurance contract or identification number | EI117-13505 | Number of Individuals Covered | 78 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $3,417 | 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 | 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 $68,348 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,417 | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | AC-32 |
Policy instance | 9 |
Insurance contract or identification number | AC-32 | Number of Individuals Covered | 103 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $360 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | 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 $5,531 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $360 | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10303631001 |
Policy instance | 10 |
Insurance contract or identification number | 10303631001 | Number of Individuals Covered | 165 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $1,198 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
Policy contract number | CLLMBLAI7 |
Policy instance | 3 |
Insurance contract or identification number | CLLMBLAI7 | Number of Individuals Covered | 107 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $35,510 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | VAR 207562 |
Policy instance | 2 |
Insurance contract or identification number | VAR 207562 | Number of Individuals Covered | 144 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $223 | Total amount of fees paid to insurance company | USD $285 | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,028 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $223 | Amount paid for insurance broker fees | 285 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | Insurance broker organization code? | 3 |
|
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL 157947 |
Policy instance | 1 |
Insurance contract or identification number | GL 157947 | Number of Individuals Covered | 144 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,443 | Total amount of fees paid to insurance company | USD $1,851 | 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 | 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 $13,115 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,443 | Amount paid for insurance broker fees | 1851 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | Insurance broker organization code? | 3 |
|
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL 157947 |
Policy instance | 1 |
Insurance contract or identification number | GL 157947 | Number of Individuals Covered | 397 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $2,966 | Total amount of fees paid to insurance company | USD $3,084 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | 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 $26,967 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,966 | Amount paid for insurance broker fees | 3084 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | Insurance broker organization code? | 3 |
|
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | VAR 207562 |
Policy instance | 2 |
Insurance contract or identification number | VAR 207562 | Number of Individuals Covered | 397 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $452 | Total amount of fees paid to insurance company | USD $511 | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $4,106 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $452 | Amount paid for insurance broker fees | 511 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | Insurance broker organization code? | 3 |
|
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
Policy contract number | CLLMBLAI2 |
Policy instance | 3 |
Insurance contract or identification number | CLLMBLAI2 | Number of Individuals Covered | 149 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $93,944 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
EYE MED VISION CARE (National Association of Insurance Commissioners NAIC id number: 98512 ) |
Policy contract number | CL VIS LAI 2 |
Policy instance | 4 |
Insurance contract or identification number | CL VIS LAI 2 | Number of Individuals Covered | 147 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $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 $19,595 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $490 | Insurance broker organization code? | 3 |
|
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | FCE0-001 |
Policy instance | 5 |
Insurance contract or identification number | FCE0-001 | Number of Individuals Covered | 150 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | 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 $2,531 | 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 | 11273-46 |
Policy instance | 6 |
Insurance contract or identification number | 11273-46 | Number of Individuals Covered | 80 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | GL 157947 |
Policy instance | 1 |
Insurance contract or identification number | GL 157947 | Number of Individuals Covered | 99 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $3,562 | Total amount of fees paid to insurance company | USD $3,238 | 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 | 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 $32,383 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,562 | Amount paid for insurance broker fees | 3238 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | Insurance broker organization code? | 3 |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | VAR 207562 |
Policy instance | 2 |
Insurance contract or identification number | VAR 207562 | Number of Individuals Covered | 99 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $552 | Total amount of fees paid to insurance company | USD $502 | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $5,016 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $552 | Amount paid for insurance broker fees | 502 | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | Insurance broker organization code? | 3 |
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COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
Policy contract number | CLLMBLAI2 |
Policy instance | 3 |
Insurance contract or identification number | CLLMBLAI2 | Number of Individuals Covered | 320 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $12,501 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $191,692 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,501 | Insurance broker organization code? | 3 |
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EYE MED VISION CARE (National Association of Insurance Commissioners NAIC id number: 98512 ) |
Policy contract number | CLLMBLAI2 |
Policy instance | 4 |
Insurance contract or identification number | CLLMBLAI2 | Number of Individuals Covered | 320 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $838 | 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 $33,533 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $838 | Insurance broker organization code? | 3 |
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PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 ) |
Policy contract number | 08537 |
Policy instance | 5 |
Insurance contract or identification number | 08537 | Number of Individuals Covered | 121 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $26,656 | 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 | 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 $533,122 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $26,656 | Insurance broker organization code? | 3 |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 11273-46 |
Policy instance | 6 |
Insurance contract or identification number | 11273-46 | Number of Individuals Covered | 89 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $82 | Total amount of fees paid to insurance company | USD $1,561 | 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 | 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 $1,643 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $82 | Amount paid for insurance broker fees | 1561 | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | GP-500B |
Policy instance | 1 |
Insurance contract or identification number | GP-500B | Number of Individuals Covered | 119 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $99,072 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $582,775 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $99,072 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | N/A | Insurance broker organization code? | 3 | Insurance broker name | THE BOON INSURANCE AGENCY, INC. |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | GP-500B |
Policy instance | 1 |
Insurance contract or identification number | GP-500B | Number of Individuals Covered | 154 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $105,270 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $658,619 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $105,270 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | N/A | Insurance broker organization code? | 3 | Insurance broker name | THE BOON INSURANCE AGENCY, INC. |
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