JACKSON-FEILD BEHAVIORAL HEALTH SERVICES has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN
401k plan membership statisitcs for JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN
Measure | Date | Value |
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2021: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-11-01 | 105 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-11-01 | 91 |
Number of retired or separated participants receiving benefits | 2021-11-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2021-11-01 | 0 |
Total of all active and inactive participants | 2021-11-01 | 94 |
2020: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-11-01 | 115 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-11-01 | 103 |
Number of retired or separated participants receiving benefits | 2020-11-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2020-11-01 | 0 |
Total of all active and inactive participants | 2020-11-01 | 105 |
2019: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-11-01 | 104 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-11-01 | 114 |
Number of retired or separated participants receiving benefits | 2019-11-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2019-11-01 | 0 |
Total of all active and inactive participants | 2019-11-01 | 115 |
2018: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-11-01 | 107 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-11-01 | 103 |
Number of retired or separated participants receiving benefits | 2018-11-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2018-11-01 | 0 |
Total of all active and inactive participants | 2018-11-01 | 104 |
2017: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-11-01 | 116 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-11-01 | 107 |
Number of retired or separated participants receiving benefits | 2017-11-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2017-11-01 | 0 |
Total of all active and inactive participants | 2017-11-01 | 107 |
2016: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-11-01 | 118 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-11-01 | 114 |
Number of retired or separated participants receiving benefits | 2016-11-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2016-11-01 | 0 |
Total of all active and inactive participants | 2016-11-01 | 116 |
2015: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-11-01 | 128 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-11-01 | 117 |
Number of retired or separated participants receiving benefits | 2015-11-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2015-11-01 | 1 |
Total of all active and inactive participants | 2015-11-01 | 118 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-11-01 | 0 |
2014: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-11-01 | 113 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-11-01 | 118 |
Number of retired or separated participants receiving benefits | 2014-11-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2014-11-01 | 1 |
Total of all active and inactive participants | 2014-11-01 | 119 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-11-01 | 0 |
Total participants, beginning-of-year | 2014-01-01 | 102 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 0 |
Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
Total of all active and inactive participants | 2014-01-01 | 0 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-01-01 | 0 |
2013: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-01-01 | 112 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 100 |
Total of all active and inactive participants | 2013-01-01 | 100 |
2012: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-01-01 | 104 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 114 |
Total of all active and inactive participants | 2012-01-01 | 114 |
Total participants | 2012-01-01 | 114 |
2011: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-01-01 | 104 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 104 |
Total of all active and inactive participants | 2011-01-01 | 104 |
2021: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2021 form 5500 responses |
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2021-11-01 | Type of plan entity | Single employer plan |
2021-11-01 | Submission has been amended | No |
2021-11-01 | This submission is the final filing | No |
2021-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-11-01 | Plan is a collectively bargained plan | No |
2021-11-01 | Plan funding arrangement – Insurance | Yes |
2021-11-01 | Plan benefit arrangement – Insurance | Yes |
2020: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2020 form 5500 responses |
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2020-11-01 | Type of plan entity | Single employer plan |
2020-11-01 | Submission has been amended | No |
2020-11-01 | This submission is the final filing | No |
2020-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-11-01 | Plan is a collectively bargained plan | No |
2020-11-01 | Plan funding arrangement – Insurance | Yes |
2020-11-01 | Plan benefit arrangement – Insurance | Yes |
2019: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2019 form 5500 responses |
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2019-11-01 | Type of plan entity | Single employer plan |
2019-11-01 | Submission has been amended | No |
2019-11-01 | This submission is the final filing | No |
2019-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-11-01 | Plan is a collectively bargained plan | No |
2019-11-01 | Plan funding arrangement – Insurance | Yes |
2019-11-01 | Plan benefit arrangement – Insurance | Yes |
2018: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2018 form 5500 responses |
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2018-11-01 | Type of plan entity | Single employer plan |
2018-11-01 | Submission has been amended | No |
2018-11-01 | This submission is the final filing | No |
2018-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-11-01 | Plan is a collectively bargained plan | No |
2018-11-01 | Plan funding arrangement – Insurance | Yes |
2018-11-01 | Plan benefit arrangement – Insurance | Yes |
2017: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2017 form 5500 responses |
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2017-11-01 | Type of plan entity | Single employer plan |
2017-11-01 | Submission has been amended | No |
2017-11-01 | This submission is the final filing | No |
2017-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-11-01 | Plan is a collectively bargained plan | No |
2017-11-01 | Plan funding arrangement – Insurance | Yes |
2017-11-01 | Plan benefit arrangement – Insurance | Yes |
2016: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2016 form 5500 responses |
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2016-11-01 | Type of plan entity | Single employer plan |
2016-11-01 | Submission has been amended | No |
2016-11-01 | This submission is the final filing | No |
2016-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-11-01 | Plan is a collectively bargained plan | No |
2016-11-01 | Plan funding arrangement – Insurance | Yes |
2016-11-01 | Plan benefit arrangement – Insurance | Yes |
2015: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2015 form 5500 responses |
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2015-11-01 | Type of plan entity | Single employer plan |
2015-11-01 | Submission has been amended | No |
2015-11-01 | This submission is the final filing | No |
2015-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-11-01 | Plan is a collectively bargained plan | No |
2015-11-01 | Plan funding arrangement – Insurance | Yes |
2015-11-01 | Plan benefit arrangement – Insurance | Yes |
2014: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2014 form 5500 responses |
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2014-11-01 | Type of plan entity | Single employer plan |
2014-11-01 | Submission has been amended | No |
2014-11-01 | This submission is the final filing | No |
2014-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-11-01 | Plan is a collectively bargained plan | No |
2014-11-01 | Plan funding arrangement – Insurance | Yes |
2014-11-01 | Plan benefit arrangement – Insurance | Yes |
2014-01-01 | Type of plan entity | Single employer plan |
2014-01-01 | Submission has been amended | No |
2014-01-01 | This submission is the final filing | Yes |
2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2014-01-01 | Plan is a collectively bargained plan | No |
2014-01-01 | Plan funding arrangement – Insurance | Yes |
2014-01-01 | Plan benefit arrangement – Insurance | Yes |
2013: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2013 form 5500 responses |
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2013-01-01 | Type of plan entity | Single employer plan |
2013-01-01 | Submission has been amended | No |
2013-01-01 | This submission is the final filing | No |
2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-01-01 | Plan is a collectively bargained plan | No |
2013-01-01 | Plan funding arrangement – Insurance | Yes |
2013-01-01 | Plan benefit arrangement – Insurance | Yes |
2012: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2012 form 5500 responses |
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2012-01-01 | Type of plan entity | Single employer plan |
2012-01-01 | Submission has been amended | No |
2012-01-01 | This submission is the final filing | No |
2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-01-01 | Plan is a collectively bargained plan | No |
2012-01-01 | Plan funding arrangement – Insurance | Yes |
2012-01-01 | Plan benefit arrangement – Insurance | Yes |
2011: JACKSON-FEILD BEHAVIORAL HEALTH SERVICES PLAN 2011 form 5500 responses |
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2011-01-01 | Type of plan entity | Single employer plan |
2011-01-01 | Submission has been amended | No |
2011-01-01 | This submission is the final filing | No |
2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-01-01 | Plan is a collectively bargained plan | No |
2011-01-01 | Plan funding arrangement – Insurance | Yes |
2011-01-01 | Plan benefit arrangement – Insurance | Yes |
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
Policy contract number | CM10001158 |
Policy instance | 3 |
Insurance contract or identification number | CM10001158 | Number of Individuals Covered | 92 | Insurance policy start date | 2021-11-01 | Insurance policy end date | 2022-10-31 | Total amount of commissions paid to insurance broker | USD $546 | Total amount of fees paid to insurance company | USD $109 | 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 | 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 $3,639 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $546 | Amount paid for insurance broker fees | 109 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 ) |
Policy contract number | VA2088 |
Policy instance | 2 |
Insurance contract or identification number | VA2088 | Number of Individuals Covered | 61 | Insurance policy start date | 2021-11-01 | Insurance policy end date | 2022-10-31 | Total amount of commissions paid to insurance broker | USD $14,504 | Total amount of fees paid to insurance company | USD $2,156 | 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 | 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 $311,939 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,504 | Amount paid for insurance broker fees | 2156 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
Policy contract number | VA2088 |
Policy instance | 1 |
Insurance contract or identification number | VA2088 | Number of Individuals Covered | 98 | Insurance policy start date | 2021-11-01 | Insurance policy end date | 2022-10-31 | Total amount of commissions paid to insurance broker | USD $6,246 | Total amount of fees paid to insurance company | USD $929 | 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 | 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 $134,334 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,246 | Amount paid for insurance broker fees | 929 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
Policy contract number | VA2088 |
Policy instance | 1 |
Insurance contract or identification number | VA2088 | Number of Individuals Covered | 122 | Insurance policy start date | 2020-11-01 | Insurance policy end date | 2021-10-31 | Total amount of commissions paid to insurance broker | USD $2,178 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $43,411 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,178 | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 0916073 |
Policy instance | 2 |
Insurance contract or identification number | 0916073 | Number of Individuals Covered | 116 | Insurance policy start date | 2020-11-01 | Insurance policy end date | 2021-10-31 | Total amount of commissions paid to insurance broker | USD $386 | 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 | Yes | 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 $6,654 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $386 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00280480 |
Policy instance | 3 |
Insurance contract or identification number | 00280480 | Number of Individuals Covered | 69 | Insurance policy start date | 2020-11-01 | Insurance policy end date | 2021-10-31 | Total amount of commissions paid to insurance broker | USD $676 | 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 $6,691 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $669 | Insurance broker organization code? | 3 |
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OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
Policy contract number | 19869 |
Policy instance | 4 |
Insurance contract or identification number | 19869 | Number of Individuals Covered | 44 | Insurance policy start date | 2020-11-01 | Insurance policy end date | 2021-10-31 | Total amount of commissions paid to insurance broker | USD $8,827 | 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 | 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 $252,408 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,827 | Insurance broker organization code? | 3 |
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OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
Policy contract number | 19874 |
Policy instance | 5 |
Insurance contract or identification number | 19874 | Number of Individuals Covered | 52 | Insurance policy start date | 2020-11-01 | Insurance policy end date | 2021-10-31 | Total amount of commissions paid to insurance broker | USD $9,050 | 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 | 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 $238,834 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,050 | Insurance broker organization code? | 3 |
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OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 ) |
Policy contract number | 66890 |
Policy instance | 6 |
Insurance contract or identification number | 66890 | Number of Individuals Covered | 21 | Insurance policy start date | 2020-11-01 | Insurance policy end date | 2021-10-31 | Total amount of commissions paid to insurance broker | USD $3,757 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $100,913 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,757 | Insurance broker organization code? | 3 |
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OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 ) |
Policy contract number | 66890*COBRA |
Policy instance | 7 |
Insurance contract or identification number | 66890*COBRA | Number of Individuals Covered | 1 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2020-10-31 | 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 | 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 $3,562 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 ) |
Policy contract number | 66890 |
Policy instance | 6 |
Insurance contract or identification number | 66890 | Number of Individuals Covered | 18 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2020-10-31 | Total amount of commissions paid to insurance broker | USD $936 | 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 | 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 $80,162 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $936 | Insurance broker organization code? | 3 |
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OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
Policy contract number | 19874 |
Policy instance | 5 |
Insurance contract or identification number | 19874 | Number of Individuals Covered | 46 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2020-10-31 | Total amount of commissions paid to insurance broker | USD $2,109 | 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 | 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 $207,413 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,109 | Insurance broker organization code? | 3 |
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OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
Policy contract number | 19869 |
Policy instance | 4 |
Insurance contract or identification number | 19869 | Number of Individuals Covered | 58 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2020-10-31 | Total amount of commissions paid to insurance broker | USD $3,605 | 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 | 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 $323,301 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,605 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00280480 |
Policy instance | 3 |
Insurance contract or identification number | 00280480 | Number of Individuals Covered | 74 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2020-10-31 | Total amount of commissions paid to insurance broker | USD $672 | 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 $6,589 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $659 | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 0916073 |
Policy instance | 2 |
Insurance contract or identification number | 0916073 | Number of Individuals Covered | 114 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2020-10-31 | Total amount of commissions paid to insurance broker | USD $409 | 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 | Yes | 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 $4,089 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $409 | Insurance broker organization code? | 3 |
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ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
Policy contract number | VA2088 |
Policy instance | 1 |
Insurance contract or identification number | VA2088 | Number of Individuals Covered | 131 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2020-10-31 | Total amount of commissions paid to insurance broker | USD $2,193 | Total amount of fees paid to insurance company | USD $231 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $41,743 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,193 | Amount paid for insurance broker fees | 231 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 0916073 |
Policy instance | 2 |
Insurance contract or identification number | 0916073 | Number of Individuals Covered | 104 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $416 | 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 | Yes | 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 $4,155 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $416 | Insurance broker organization code? | 3 |
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ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
Policy contract number | VA2088 |
Policy instance | 1 |
Insurance contract or identification number | VA2088 | Number of Individuals Covered | 132 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $1,683 | Total amount of fees paid to insurance company | USD $2,867 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $40,596 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,683 | Amount paid for insurance broker fees | 2867 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00280480 |
Policy instance | 3 |
Insurance contract or identification number | 00280480 | Number of Individuals Covered | 69 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $576 | 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 $5,796 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $576 | Insurance broker organization code? | 3 |
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OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
Policy contract number | 19869 |
Policy instance | 4 |
Insurance contract or identification number | 19869 | Number of Individuals Covered | 98 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $3,936 | 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 | 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 $430,628 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,936 | Insurance broker organization code? | 3 |
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OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
Policy contract number | 19874 |
Policy instance | 5 |
Insurance contract or identification number | 19874 | Number of Individuals Covered | 2 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $103 | 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 | 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 $11,900 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $103 | Insurance broker organization code? | 3 |
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OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 ) |
Policy contract number | 66890 |
Policy instance | 6 |
Insurance contract or identification number | 66890 | Number of Individuals Covered | 21 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $1,043 | 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 | 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 $112,415 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,043 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00280480 |
Policy instance | 4 |
Insurance contract or identification number | 00280480 | Number of Individuals Covered | 107 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $1,337 | 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 | Yes | 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 $10,708 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
Policy contract number | 000600397 |
Policy instance | 3 |
Insurance contract or identification number | 000600397 | Number of Individuals Covered | 122 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $2,501 | 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 | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $49,081 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0767345 |
Policy instance | 1 |
Insurance contract or identification number | 0767345 | Number of Individuals Covered | 39 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $4,527 | 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 | 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 $158,194 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
Policy contract number | 0767345HNO |
Policy instance | 2 |
Insurance contract or identification number | 0767345HNO | Number of Individuals Covered | 80 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $9,186 | 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 | 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 $325,712 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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