WESTERN BRANCH DIESEL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan WESTERN BRANCH DIESEL, INC. FLEXIBLE BENEFITS PLAN
401k plan membership statisitcs for WESTERN BRANCH DIESEL, INC. FLEXIBLE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2014 : WESTERN BRANCH DIESEL, INC. FLEXIBLE BENEFITS PLAN 2014 401k financial data |
|---|
| Unrealized appreciation/depreciation of real estate assets | 2014-06-30 | $0 |
| Unrealized appreciation/depreciation of other (non real estate) assets | 2014-06-30 | $0 |
| Total unrealized appreciation/depreciation of assets | 2014-06-30 | $0 |
| Total transfer of assets to this plan | 2014-06-30 | $0 |
| Total transfer of assets from this plan | 2014-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-06-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-06-30 | $0 |
| Expenses. Interest paid | 2014-06-30 | $0 |
| Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102 | 2014-06-30 | $0 |
| Total income from all sources (including contributions) | 2014-06-30 | $2,995,353 |
| Total loss/gain on sale of assets | 2014-06-30 | $0 |
| Total of all expenses incurred | 2014-06-30 | $3,097,376 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-06-30 | $3,084,730 |
| Expenses. Certain deemed distributions of participant loans | 2014-06-30 | $0 |
| Value of total corrective distributions | 2014-06-30 | $0 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-06-30 | $2,995,353 |
| Value of total assets at end of year | 2014-06-30 | $0 |
| Value of total assets at beginning of year | 2014-06-30 | $102,023 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-06-30 | $12,646 |
| Total income from rents | 2014-06-30 | $0 |
| Total interest from all sources | 2014-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-06-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-06-30 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2014-06-30 | $0 |
| Assets. Real estate other than employer real property at end of year | 2014-06-30 | $0 |
| Assets. Real estate other than employer real property at beginning of year | 2014-06-30 | $0 |
| Administrative expenses professional fees incurred | 2014-06-30 | $0 |
| Was this plan covered by a fidelity bond | 2014-06-30 | Yes |
| Value of fidelity bond cover | 2014-06-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2014-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-06-30 | No |
| Contributions received from participants | 2014-06-30 | $677,041 |
| Participant contributions at end of year | 2014-06-30 | $0 |
| Participant contributions at beginning of year | 2014-06-30 | $0 |
| Participant contributions at end of year | 2014-06-30 | $0 |
| Participant contributions at beginning of year | 2014-06-30 | $0 |
| Assets. Other investments not covered elsewhere at end of year | 2014-06-30 | $0 |
| Assets. Other investments not covered elsewhere at beginning of year | 2014-06-30 | $0 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2014-06-30 | $0 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2014-06-30 | $238,014 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2014-06-30 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2014-06-30 | $0 |
| Assets. Loans (other than to participants) at end of year | 2014-06-30 | $0 |
| Assets. Loans (other than to participants) at beginning of year | 2014-06-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2014-06-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2014-06-30 | $0 |
| Other income not declared elsewhere | 2014-06-30 | $0 |
| Administrative expenses (other) incurred | 2014-06-30 | $0 |
| Liabilities. Value of operating payables at end of year | 2014-06-30 | $0 |
| Liabilities. Value of operating payables at beginning of year | 2014-06-30 | $0 |
| Total non interest bearing cash at end of year | 2014-06-30 | $0 |
| Total non interest bearing cash at beginning of year | 2014-06-30 | $102,023 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-06-30 | No |
| Income. Non cash contributions | 2014-06-30 | $0 |
| Value of net income/loss | 2014-06-30 | $-102,023 |
| Value of net assets at end of year (total assets less liabilities) | 2014-06-30 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-06-30 | $102,023 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-06-30 | No |
| Assets. partnership/joint venture interests at end of year | 2014-06-30 | $0 |
| Assets. partnership/joint venture interests at beginning of year | 2014-06-30 | $0 |
| Investment advisory and management fees | 2014-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2014-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2014-06-30 | $0 |
| Interest on participant loans | 2014-06-30 | $0 |
| Income. Interest from loans (other than to participants) | 2014-06-30 | $0 |
| Interest earned on other investments | 2014-06-30 | $0 |
| Income. Interest from US Government securities | 2014-06-30 | $0 |
| Income. Interest from corporate debt instruments | 2014-06-30 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2014-06-30 | $0 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2014-06-30 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2014-06-30 | $0 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2014-06-30 | $0 |
| Value of funds held in insurance company general accounts (unallocated contracts) at end of year | 2014-06-30 | $0 |
| Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year | 2014-06-30 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-06-30 | $2,846,716 |
| Asset value of US Government securities at end of year | 2014-06-30 | $0 |
| Asset value of US Government securities at beginning of year | 2014-06-30 | $0 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2014-06-30 | $0 |
| Net investment gain/loss from pooled separate accounts | 2014-06-30 | $0 |
| Net investment gain or loss from common/collective trusts | 2014-06-30 | $0 |
| Net gain/loss from 103.12 investment entities | 2014-06-30 | $0 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-06-30 | No |
| Assets. Invements in employer securities at end of year | 2014-06-30 | $0 |
| Assets. Invements in employer securities at beginning of year | 2014-06-30 | $0 |
| Assets. Value of employer real property at end of year | 2014-06-30 | $0 |
| Assets. Value of employer real property at beginning of year | 2014-06-30 | $0 |
| Contributions received in cash from employer | 2014-06-30 | $2,318,312 |
| Employer contributions (assets) at end of year | 2014-06-30 | $0 |
| Employer contributions (assets) at beginning of year | 2014-06-30 | $0 |
| Income. Dividends from preferred stock | 2014-06-30 | $0 |
| Income. Dividends from common stock | 2014-06-30 | $0 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-06-30 | $0 |
| Asset. Corporate debt instrument preferred debt at end of year | 2014-06-30 | $0 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2014-06-30 | $0 |
| Asset. Corporate debt instrument debt (other) at end of year | 2014-06-30 | $0 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2014-06-30 | $0 |
| Contract administrator fees | 2014-06-30 | $12,646 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2014-06-30 | $0 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2014-06-30 | $0 |
| Liabilities. Value of benefit claims payable at end of year | 2014-06-30 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2014-06-30 | $0 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2014-06-30 | $0 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2014-06-30 | $0 |
| Did the plan have assets held for investment | 2014-06-30 | 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 | 2014-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-06-30 | Yes |
| Aggregate proceeds on sale of assets | 2014-06-30 | $0 |
| Aggregate carrying amount (costs) on sale of assets | 2014-06-30 | $0 |
| Liabilities. Value of acquisition indebtedness at end of year | 2014-06-30 | $0 |
| Liabilities. Value of acquisition indebtedness at beginning of year | 2014-06-30 | $0 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-06-30 | Unqualified |
| Accountancy firm name | 2014-06-30 | DIXON HUGHES GOODMAN LLP |
| Accountancy firm EIN | 2014-06-30 | 560747981 |
| 2013 : WESTERN BRANCH DIESEL, INC. FLEXIBLE BENEFITS PLAN 2013 401k financial data |
|---|
| Unrealized appreciation/depreciation of real estate assets | 2013-06-30 | $0 |
| Unrealized appreciation/depreciation of other (non real estate) assets | 2013-06-30 | $0 |
| Total unrealized appreciation/depreciation of assets | 2013-06-30 | $0 |
| Total transfer of assets to this plan | 2013-06-30 | $0 |
| Total transfer of assets from this plan | 2013-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-06-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-06-30 | $0 |
| Expenses. Interest paid | 2013-06-30 | $0 |
| Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102 | 2013-06-30 | $0 |
| Total income from all sources (including contributions) | 2013-06-30 | $2,897,708 |
| Total loss/gain on sale of assets | 2013-06-30 | $25,592 |
| Total of all expenses incurred | 2013-06-30 | $3,165,277 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-06-30 | $3,151,855 |
| Expenses. Certain deemed distributions of participant loans | 2013-06-30 | $0 |
| Value of total corrective distributions | 2013-06-30 | $0 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-06-30 | $2,866,809 |
| Value of total assets at end of year | 2013-06-30 | $102,023 |
| Value of total assets at beginning of year | 2013-06-30 | $369,592 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-06-30 | $13,422 |
| Total income from rents | 2013-06-30 | $0 |
| Total interest from all sources | 2013-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-06-30 | $5,307 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-06-30 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2013-06-30 | $0 |
| Assets. Real estate other than employer real property at end of year | 2013-06-30 | $0 |
| Assets. Real estate other than employer real property at beginning of year | 2013-06-30 | $0 |
| Administrative expenses professional fees incurred | 2013-06-30 | $0 |
| Was this plan covered by a fidelity bond | 2013-06-30 | Yes |
| Value of fidelity bond cover | 2013-06-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2013-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-06-30 | No |
| Contributions received from participants | 2013-06-30 | $692,616 |
| Participant contributions at end of year | 2013-06-30 | $0 |
| Participant contributions at beginning of year | 2013-06-30 | $0 |
| Participant contributions at end of year | 2013-06-30 | $0 |
| Participant contributions at beginning of year | 2013-06-30 | $0 |
| Assets. Other investments not covered elsewhere at end of year | 2013-06-30 | $0 |
| Assets. Other investments not covered elsewhere at beginning of year | 2013-06-30 | $0 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2013-06-30 | $0 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2013-06-30 | $5,703 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-06-30 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-06-30 | $0 |
| Assets. Loans (other than to participants) at end of year | 2013-06-30 | $0 |
| Assets. Loans (other than to participants) at beginning of year | 2013-06-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2013-06-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2013-06-30 | $0 |
| Other income not declared elsewhere | 2013-06-30 | $0 |
| Administrative expenses (other) incurred | 2013-06-30 | $0 |
| Liabilities. Value of operating payables at end of year | 2013-06-30 | $0 |
| Liabilities. Value of operating payables at beginning of year | 2013-06-30 | $0 |
| Total non interest bearing cash at end of year | 2013-06-30 | $102,023 |
| Total non interest bearing cash at beginning of year | 2013-06-30 | $27,103 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-06-30 | No |
| Income. Non cash contributions | 2013-06-30 | $0 |
| Value of net income/loss | 2013-06-30 | $-267,569 |
| Value of net assets at end of year (total assets less liabilities) | 2013-06-30 | $102,023 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-06-30 | $369,592 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-06-30 | No |
| Assets. partnership/joint venture interests at end of year | 2013-06-30 | $0 |
| Assets. partnership/joint venture interests at beginning of year | 2013-06-30 | $0 |
| Investment advisory and management fees | 2013-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2013-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2013-06-30 | $0 |
| Interest on participant loans | 2013-06-30 | $0 |
| Income. Interest from loans (other than to participants) | 2013-06-30 | $0 |
| Interest earned on other investments | 2013-06-30 | $0 |
| Income. Interest from US Government securities | 2013-06-30 | $0 |
| Income. Interest from corporate debt instruments | 2013-06-30 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2013-06-30 | $0 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2013-06-30 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2013-06-30 | $0 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2013-06-30 | $0 |
| Value of funds held in insurance company general accounts (unallocated contracts) at end of year | 2013-06-30 | $0 |
| Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year | 2013-06-30 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-06-30 | $3,146,152 |
| Asset value of US Government securities at end of year | 2013-06-30 | $0 |
| Asset value of US Government securities at beginning of year | 2013-06-30 | $0 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2013-06-30 | $0 |
| Net investment gain/loss from pooled separate accounts | 2013-06-30 | $0 |
| Net investment gain or loss from common/collective trusts | 2013-06-30 | $0 |
| Net gain/loss from 103.12 investment entities | 2013-06-30 | $0 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-06-30 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2013-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-06-30 | No |
| Assets. Invements in employer securities at end of year | 2013-06-30 | $0 |
| Assets. Invements in employer securities at beginning of year | 2013-06-30 | $0 |
| Assets. Value of employer real property at end of year | 2013-06-30 | $0 |
| Assets. Value of employer real property at beginning of year | 2013-06-30 | $0 |
| Contributions received in cash from employer | 2013-06-30 | $2,174,193 |
| Employer contributions (assets) at end of year | 2013-06-30 | $0 |
| Employer contributions (assets) at beginning of year | 2013-06-30 | $0 |
| Income. Dividends from preferred stock | 2013-06-30 | $0 |
| Income. Dividends from common stock | 2013-06-30 | $5,307 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-06-30 | $0 |
| Asset. Corporate debt instrument preferred debt at end of year | 2013-06-30 | $0 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2013-06-30 | $0 |
| Asset. Corporate debt instrument debt (other) at end of year | 2013-06-30 | $0 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2013-06-30 | $0 |
| Contract administrator fees | 2013-06-30 | $13,422 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2013-06-30 | $0 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2013-06-30 | $342,489 |
| Liabilities. Value of benefit claims payable at end of year | 2013-06-30 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2013-06-30 | $0 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2013-06-30 | $0 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2013-06-30 | $0 |
| Did the plan have assets held for investment | 2013-06-30 | 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 | 2013-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-06-30 | No |
| Aggregate proceeds on sale of assets | 2013-06-30 | $25,592 |
| Aggregate carrying amount (costs) on sale of assets | 2013-06-30 | $0 |
| Liabilities. Value of acquisition indebtedness at end of year | 2013-06-30 | $0 |
| Liabilities. Value of acquisition indebtedness at beginning of year | 2013-06-30 | $0 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-06-30 | Unqualified |
| Accountancy firm name | 2013-06-30 | DIXON HUGHES GOODMAN LLP |
| Accountancy firm EIN | 2013-06-30 | 560747981 |
| 2012 : WESTERN BRANCH DIESEL, INC. FLEXIBLE BENEFITS PLAN 2012 401k financial data |
|---|
| Unrealized appreciation/depreciation of real estate assets | 2012-06-30 | $0 |
| Unrealized appreciation/depreciation of other (non real estate) assets | 2012-06-30 | $-86,908 |
| Total unrealized appreciation/depreciation of assets | 2012-06-30 | $-86,908 |
| Total transfer of assets to this plan | 2012-06-30 | $0 |
| Total transfer of assets from this plan | 2012-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-06-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-06-30 | $0 |
| Expenses. Interest paid | 2012-06-30 | $0 |
| Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102 | 2012-06-30 | $0 |
| Total income from all sources (including contributions) | 2012-06-30 | $2,663,971 |
| Total loss/gain on sale of assets | 2012-06-30 | $-39,103 |
| Total of all expenses incurred | 2012-06-30 | $3,041,516 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-06-30 | $3,029,725 |
| Expenses. Certain deemed distributions of participant loans | 2012-06-30 | $0 |
| Value of total corrective distributions | 2012-06-30 | $0 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-06-30 | $2,781,154 |
| Value of total assets at end of year | 2012-06-30 | $369,592 |
| Value of total assets at beginning of year | 2012-06-30 | $747,137 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-06-30 | $11,791 |
| Total income from rents | 2012-06-30 | $0 |
| Total interest from all sources | 2012-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-06-30 | $8,828 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-06-30 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2012-06-30 | $0 |
| Assets. Real estate other than employer real property at end of year | 2012-06-30 | $0 |
| Assets. Real estate other than employer real property at beginning of year | 2012-06-30 | $0 |
| Administrative expenses professional fees incurred | 2012-06-30 | $0 |
| Assets. Corporate prefeered stocks other than exployer securities at end of year | 2012-06-30 | $0 |
| Assets. Corporate prefeered stocks other than exployer securities at beginning of year | 2012-06-30 | $0 |
| Was this plan covered by a fidelity bond | 2012-06-30 | Yes |
| Value of fidelity bond cover | 2012-06-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2012-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-06-30 | No |
| Contributions received from participants | 2012-06-30 | $665,404 |
| Participant contributions at end of year | 2012-06-30 | $0 |
| Participant contributions at beginning of year | 2012-06-30 | $0 |
| Participant contributions at end of year | 2012-06-30 | $0 |
| Participant contributions at beginning of year | 2012-06-30 | $0 |
| Assets. Other investments not covered elsewhere at end of year | 2012-06-30 | $0 |
| Assets. Other investments not covered elsewhere at beginning of year | 2012-06-30 | $0 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2012-06-30 | $5,703 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2012-06-30 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-06-30 | $0 |
| Assets. Loans (other than to participants) at end of year | 2012-06-30 | $0 |
| Assets. Loans (other than to participants) at beginning of year | 2012-06-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2012-06-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2012-06-30 | $0 |
| Other income not declared elsewhere | 2012-06-30 | $0 |
| Administrative expenses (other) incurred | 2012-06-30 | $0 |
| Liabilities. Value of operating payables at end of year | 2012-06-30 | $0 |
| Liabilities. Value of operating payables at beginning of year | 2012-06-30 | $0 |
| Total non interest bearing cash at end of year | 2012-06-30 | $27,103 |
| Total non interest bearing cash at beginning of year | 2012-06-30 | $762 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-06-30 | No |
| Value of net income/loss | 2012-06-30 | $-377,545 |
| Value of net assets at end of year (total assets less liabilities) | 2012-06-30 | $369,592 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-06-30 | $747,137 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-06-30 | No |
| Assets. partnership/joint venture interests at end of year | 2012-06-30 | $0 |
| Assets. partnership/joint venture interests at beginning of year | 2012-06-30 | $0 |
| Investment advisory and management fees | 2012-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2012-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2012-06-30 | $0 |
| Interest on participant loans | 2012-06-30 | $0 |
| Income. Interest from loans (other than to participants) | 2012-06-30 | $0 |
| Interest earned on other investments | 2012-06-30 | $0 |
| Income. Interest from US Government securities | 2012-06-30 | $0 |
| Income. Interest from corporate debt instruments | 2012-06-30 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2012-06-30 | $0 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-06-30 | $16,242 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-06-30 | $16,242 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2012-06-30 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-06-30 | $3,024,022 |
| Asset value of US Government securities at end of year | 2012-06-30 | $0 |
| Asset value of US Government securities at beginning of year | 2012-06-30 | $0 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2012-06-30 | $0 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-06-30 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2012-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-06-30 | No |
| Assets. Invements in employer securities at end of year | 2012-06-30 | $0 |
| Assets. Invements in employer securities at beginning of year | 2012-06-30 | $0 |
| Assets. Value of employer real property at end of year | 2012-06-30 | $0 |
| Assets. Value of employer real property at beginning of year | 2012-06-30 | $0 |
| Contributions received in cash from employer | 2012-06-30 | $2,115,750 |
| Employer contributions (assets) at end of year | 2012-06-30 | $0 |
| Employer contributions (assets) at beginning of year | 2012-06-30 | $0 |
| Income. Dividends from preferred stock | 2012-06-30 | $0 |
| Income. Dividends from common stock | 2012-06-30 | $8,828 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-06-30 | $0 |
| Asset. Corporate debt instrument preferred debt at end of year | 2012-06-30 | $0 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2012-06-30 | $0 |
| Asset. Corporate debt instrument debt (other) at end of year | 2012-06-30 | $0 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2012-06-30 | $0 |
| Contract administrator fees | 2012-06-30 | $11,791 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2012-06-30 | $342,489 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2012-06-30 | $730,133 |
| Liabilities. Value of benefit claims payable at end of year | 2012-06-30 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2012-06-30 | $0 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2012-06-30 | $0 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2012-06-30 | $0 |
| Did the plan have assets held for investment | 2012-06-30 | Yes |
| 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 | 2012-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-06-30 | No |
| Aggregate proceeds on sale of assets | 2012-06-30 | $261,635 |
| Aggregate carrying amount (costs) on sale of assets | 2012-06-30 | $300,738 |
| Liabilities. Value of acquisition indebtedness at end of year | 2012-06-30 | $0 |
| Liabilities. Value of acquisition indebtedness at beginning of year | 2012-06-30 | $0 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-06-30 | Unqualified |
| Accountancy firm name | 2012-06-30 | DIXON HUGHES GOODMAN LLP |
| Accountancy firm EIN | 2012-06-30 | 560747981 |
| 2011 : WESTERN BRANCH DIESEL, INC. FLEXIBLE BENEFITS PLAN 2011 401k financial data |
|---|
| Unrealized appreciation/depreciation of real estate assets | 2011-06-30 | $0 |
| Unrealized appreciation/depreciation of other (non real estate) assets | 2011-06-30 | $318,943 |
| Total unrealized appreciation/depreciation of assets | 2011-06-30 | $318,943 |
| Total transfer of assets to this plan | 2011-06-30 | $0 |
| Total transfer of assets from this plan | 2011-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-06-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-06-30 | $0 |
| Expenses. Interest paid | 2011-06-30 | $0 |
| Amount of participant contributions which was failed to transmit to the plan within the time period described in 29 CFR 251.3-102 | 2011-06-30 | $0 |
| Total income from all sources (including contributions) | 2011-06-30 | $2,944,530 |
| Total loss/gain on sale of assets | 2011-06-30 | $-23,691 |
| Total of all expenses incurred | 2011-06-30 | $2,872,012 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-06-30 | $2,859,716 |
| Expenses. Certain deemed distributions of participant loans | 2011-06-30 | $0 |
| Value of total corrective distributions | 2011-06-30 | $0 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-06-30 | $2,642,890 |
| Value of total assets at end of year | 2011-06-30 | $747,137 |
| Value of total assets at beginning of year | 2011-06-30 | $674,619 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-06-30 | $12,296 |
| Total income from rents | 2011-06-30 | $0 |
| Total interest from all sources | 2011-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-06-30 | $6,388 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-06-30 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2011-06-30 | $0 |
| Assets. Real estate other than employer real property at end of year | 2011-06-30 | $0 |
| Assets. Real estate other than employer real property at beginning of year | 2011-06-30 | $0 |
| Administrative expenses professional fees incurred | 2011-06-30 | $0 |
| Assets. Corporate prefeered stocks other than exployer securities at end of year | 2011-06-30 | $0 |
| Assets. Corporate prefeered stocks other than exployer securities at beginning of year | 2011-06-30 | $0 |
| Was this plan covered by a fidelity bond | 2011-06-30 | Yes |
| Value of fidelity bond cover | 2011-06-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2011-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-06-30 | No |
| Contributions received from participants | 2011-06-30 | $637,528 |
| Participant contributions at end of year | 2011-06-30 | $0 |
| Participant contributions at beginning of year | 2011-06-30 | $0 |
| Participant contributions at end of year | 2011-06-30 | $0 |
| Participant contributions at beginning of year | 2011-06-30 | $0 |
| Assets. Other investments not covered elsewhere at end of year | 2011-06-30 | $0 |
| Assets. Other investments not covered elsewhere at beginning of year | 2011-06-30 | $0 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2011-06-30 | $0 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2011-06-30 | $5,703 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-06-30 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-06-30 | $0 |
| Assets. Loans (other than to participants) at end of year | 2011-06-30 | $0 |
| Assets. Loans (other than to participants) at beginning of year | 2011-06-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2011-06-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2011-06-30 | $0 |
| Other income not declared elsewhere | 2011-06-30 | $0 |
| Administrative expenses (other) incurred | 2011-06-30 | $0 |
| Liabilities. Value of operating payables at end of year | 2011-06-30 | $0 |
| Liabilities. Value of operating payables at beginning of year | 2011-06-30 | $0 |
| Total non interest bearing cash at end of year | 2011-06-30 | $762 |
| Total non interest bearing cash at beginning of year | 2011-06-30 | $293 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-06-30 | No |
| Income. Non cash contributions | 2011-06-30 | $0 |
| Value of net income/loss | 2011-06-30 | $72,518 |
| Value of net assets at end of year (total assets less liabilities) | 2011-06-30 | $747,137 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-06-30 | $674,619 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-06-30 | No |
| Assets. partnership/joint venture interests at end of year | 2011-06-30 | $0 |
| Assets. partnership/joint venture interests at beginning of year | 2011-06-30 | $0 |
| Investment advisory and management fees | 2011-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2011-06-30 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2011-06-30 | $0 |
| Value of interest in pooled separate accounts at end of year | 2011-06-30 | $0 |
| Value of interest in pooled separate accounts at beginning of year | 2011-06-30 | $0 |
| Interest on participant loans | 2011-06-30 | $0 |
| Income. Interest from loans (other than to participants) | 2011-06-30 | $0 |
| Interest earned on other investments | 2011-06-30 | $0 |
| Income. Interest from US Government securities | 2011-06-30 | $0 |
| Income. Interest from corporate debt instruments | 2011-06-30 | $0 |
| Value of interest in master investment trust accounts at end of year | 2011-06-30 | $0 |
| Value of interest in master investment trust accounts at beginning of year | 2011-06-30 | $0 |
| Value of interest in common/collective trusts at end of year | 2011-06-30 | $0 |
| Value of interest in common/collective trusts at beginning of year | 2011-06-30 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-06-30 | $16,242 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-06-30 | $12,571 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-06-30 | $12,571 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-06-30 | $0 |
| Assets. Value of investments in 103.12 investment entities at end of year | 2011-06-30 | $0 |
| Assets. Value of investments in 103.12 investment entities at beginning of year | 2011-06-30 | $0 |
| Value of funds held in insurance company general accounts (unallocated contracts) at end of year | 2011-06-30 | $0 |
| Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year | 2011-06-30 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-06-30 | $2,854,013 |
| Asset value of US Government securities at end of year | 2011-06-30 | $0 |
| Asset value of US Government securities at beginning of year | 2011-06-30 | $0 |
| Net investment gain/loss from registered investment companies (e.g. mutual funds) | 2011-06-30 | $0 |
| Net investment gain/loss from pooled separate accounts | 2011-06-30 | $0 |
| Net investment gain or loss from common/collective trusts | 2011-06-30 | $0 |
| Net gain/loss from 103.12 investment entities | 2011-06-30 | $0 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-06-30 | No |
| Assets. Invements in employer securities at end of year | 2011-06-30 | $0 |
| Assets. Invements in employer securities at beginning of year | 2011-06-30 | $0 |
| Assets. Value of employer real property at end of year | 2011-06-30 | $0 |
| Assets. Value of employer real property at beginning of year | 2011-06-30 | $0 |
| Contributions received in cash from employer | 2011-06-30 | $2,005,362 |
| Employer contributions (assets) at end of year | 2011-06-30 | $0 |
| Employer contributions (assets) at beginning of year | 2011-06-30 | $0 |
| Income. Dividends from preferred stock | 2011-06-30 | $0 |
| Income. Dividends from common stock | 2011-06-30 | $6,388 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-06-30 | $0 |
| Asset. Corporate debt instrument preferred debt at end of year | 2011-06-30 | $0 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2011-06-30 | $0 |
| Asset. Corporate debt instrument debt (other) at end of year | 2011-06-30 | $0 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2011-06-30 | $0 |
| Contract administrator fees | 2011-06-30 | $12,296 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2011-06-30 | $730,133 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2011-06-30 | $661,755 |
| Liabilities. Value of benefit claims payable at end of year | 2011-06-30 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2011-06-30 | $0 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2011-06-30 | $0 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2011-06-30 | $0 |
| Did the plan have assets held for investment | 2011-06-30 | Yes |
| 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 | 2011-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-06-30 | No |
| Aggregate proceeds on sale of assets | 2011-06-30 | $226,873 |
| Aggregate carrying amount (costs) on sale of assets | 2011-06-30 | $250,564 |
| Liabilities. Value of acquisition indebtedness at end of year | 2011-06-30 | $0 |
| Liabilities. Value of acquisition indebtedness at beginning of year | 2011-06-30 | $0 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-06-30 | Unqualified |
| Accountancy firm name | 2011-06-30 | DIXON HUGHES GOODMAN, LLP |
| Accountancy firm EIN | 2011-06-30 | 560747981 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BKLN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0BKLN | | Number of Individuals Covered | 120 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,179 | | 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 & 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 $11,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,179 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0BKLN |
| Policy instance | 5 |
| Insurance contract or identification number | GUG0BKLN | | Number of Individuals Covered | 143 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2021-09-30 | | 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 | Yes | | 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 $14,090 | | 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 | 10007441001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10007441001 | | Number of Individuals Covered | 376 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2021-09-30 | | 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 $4,933 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00562223 |
| Policy instance | 2 |
| Insurance contract or identification number | 00562223 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $392 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $392 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0BKLN |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0BKLN | | Number of Individuals Covered | 255 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2021-09-30 | | 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 | Yes | | 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 $9,805 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BKLN |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BKLN | | Number of Individuals Covered | 255 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2021-09-30 | | 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 & 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 $3,828 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BKLN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0BKLN | | Number of Individuals Covered | 100 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $3,795 | | Total amount of fees paid to insurance company | USD $1,746 | | 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 & 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 $45,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,795 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1746 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10007441001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10007441001 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | 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 $20,469 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00562223 |
| Policy instance | 2 |
| Insurance contract or identification number | 00562223 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $3,775 | | Total amount of fees paid to insurance company | USD $1,679 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $27,749 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,775 | | Amount paid for insurance broker fees | 1679 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0BKLN |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0BKLN | | Number of Individuals Covered | 248 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,401 | | 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 | Yes | | 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 $35,849 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1401 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BKLN |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BKLN | | Number of Individuals Covered | 248 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $713 | | 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 & 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 $17,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 713 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0BKLN |
| Policy instance | 5 |
| Insurance contract or identification number | GUG0BKLN | | Number of Individuals Covered | 130 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,879 | | 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 | Yes | | 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 $47,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1879 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10007441001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10007441001 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | 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 $20,195 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00562223 |
| Policy instance | 2 |
| Insurance contract or identification number | 00562223 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $16,767 | | Total amount of fees paid to insurance company | USD $1,067 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $27,946 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,767 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1067 | | Additional information about fees paid to insurance broker | FEES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0BKLN |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0BKLN | | Number of Individuals Covered | 231 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,235 | | 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 | Yes | | 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 $37,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1235 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BKLN |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BKLN | | Number of Individuals Covered | 231 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $634 | | 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 & 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 $19,830 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 634 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0BKLN |
| Policy instance | 5 |
| Insurance contract or identification number | GUG0BKLN | | Number of Individuals Covered | 127 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,787 | | 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 | Yes | | 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 $51,618 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1787 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BKLN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0BKLN | | Number of Individuals Covered | 97 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $3,828 | | Total amount of fees paid to insurance company | USD $1,760 | | 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 & 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 $46,554 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,828 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1760 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 878347G |
| Policy instance | 7 |
| Insurance contract or identification number | 878347G | | Number of Individuals Covered | 284 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,742 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,920 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1719 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10007441001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10007441001 | | Number of Individuals Covered | 376 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | 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 $20,463 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 878347G |
| Policy instance | 1 |
| Insurance contract or identification number | 878347G | | Number of Individuals Covered | 284 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $3,405 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $205,307 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3235 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 ) |
| Policy contract number | 06676 |
| Policy instance | 3 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | 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 $1,264,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 878347G |
| Policy instance | 2 |
| Insurance contract or identification number | 878347G | | Number of Individuals Covered | 281 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $7,045 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $177,691 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 6242 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 | | Insurance broker name | AON RISK SERVICES CENTRAL INC |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 06676 |
| Policy instance | 1 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | 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 $1,240,607 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0865117 |
| Policy instance | 1 |
| Insurance contract or identification number | 0865117 | | Number of Individuals Covered | 459 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $245,681 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 06676 |
| Policy instance | 2 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 450 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | 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 $2,453,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0865117 |
| Policy instance | 1 |
| Insurance contract or identification number | 0865117 | | Number of Individuals Covered | 489 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $226,326 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 754367 |
| Policy instance | 2 |
| Insurance contract or identification number | 754367 | | Number of Individuals Covered | 467 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,874 | | 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 $2,492,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,874 | | Insurance broker organization code? | 3 | | Insurance broker name | AON CONSULTING INC - RICHMOND VA |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | AL00003138 |
| Policy instance | 1 |
| Insurance contract or identification number | AL00003138 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISBURMEMBERMENT, STD & LTD BUY UP SUPPLEMENT LIFE & AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $27,158 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0865117 |
| Policy instance | 2 |
| Insurance contract or identification number | 0865117 | | Number of Individuals Covered | 488 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $221,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 754367 |
| Policy instance | 3 |
| Insurance contract or identification number | 754367 | | Number of Individuals Covered | 484 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | 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 $2,346,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 ) |
| Policy contract number | 06676 |
| Policy instance | 2 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | 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 $893,658 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | AL00003138 |
| Policy instance | 3 |
| Insurance contract or identification number | AL00003138 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISBURMEMBERMENT, STD & LTD BUY UP SUPPLEMENT LIFE & AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $299,028 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 06676 |
| Policy instance | 1 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | 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 $1,815,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 ) |
| Policy contract number | 06676 |
| Policy instance | 3 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | 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 $948,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | AL00003138 |
| Policy instance | 2 |
| Insurance contract or identification number | AL00003138 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISBURMEMBERMENT, STD & LTD BUY UP SUPPLEMENT LIFE & AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $289,576 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 06676 |
| Policy instance | 1 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | 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 $1,656,557 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 06676 |
| Policy instance | 1 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 291 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | 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 $1,653,745 |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | AL00003138 |
| Policy instance | 2 |
| Insurance contract or identification number | AL00003138 | | Number of Individuals Covered | 254 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISBURMEMBERMENT, STD & LTD BUY UP SUPPLEMENT LIFE & AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $266,306 |
|
| HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 ) |
| Policy contract number | 06676 |
| Policy instance | 3 |
| Insurance contract or identification number | 06676 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | 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 $773,215 |
|
