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WINTERGREEN FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan NameWINTERGREEN FLEXIBLE BENEFITS PLAN
Plan identification number 501

WINTERGREEN FLEXIBLE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

WINTERGREEN PARTNERS, INC. has sponsored the creation of one or more 401k plans.

Company Name:WINTERGREEN PARTNERS, INC.
Employer identification number (EIN):541286721
NAIC Classification:721110
NAIC Description:Hotels (except Casino Hotels) and Motels

Additional information about WINTERGREEN PARTNERS, INC.

Jurisdiction of Incorporation: Virginia Secretary of State
Incorporation Date: 1984-05-23
Company Identification Number: 0256723
Legal Registered Office Address: 4701 COX ROAD
SUITE 301
GLEN ALLEN
United States of America (USA)
23060-6802

More information about WINTERGREEN PARTNERS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WINTERGREEN FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012015-10-01DANIEL SCHABLEIN
5012014-10-01DANIEL SCHABLEIN
5012013-10-01DAN SCHABLEIL
5012012-10-01DAN SCHABLEIN
5012011-10-01DAN SCHABLEIN
5012010-10-01DAN SCHABLEIN
5012009-10-01DAN SCHABLEIN

Plan Statistics for WINTERGREEN FLEXIBLE BENEFITS PLAN

401k plan membership statisitcs for WINTERGREEN FLEXIBLE BENEFITS PLAN

Measure Date Value
2015: WINTERGREEN FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01242
Total number of active participants reported on line 7a of the Form 55002015-10-01227
Number of retired or separated participants receiving benefits2015-10-010
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-01227
2014: WINTERGREEN FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-10-01248
Total number of active participants reported on line 7a of the Form 55002014-10-01242
Number of retired or separated participants receiving benefits2014-10-010
Number of other retired or separated participants entitled to future benefits2014-10-010
Total of all active and inactive participants2014-10-01242
2013: WINTERGREEN FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-10-01185
Total number of active participants reported on line 7a of the Form 55002013-10-01248
Number of retired or separated participants receiving benefits2013-10-010
Number of other retired or separated participants entitled to future benefits2013-10-010
Total of all active and inactive participants2013-10-01248
2012: WINTERGREEN FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-10-01210
Total number of active participants reported on line 7a of the Form 55002012-10-01185
Number of retired or separated participants receiving benefits2012-10-010
Number of other retired or separated participants entitled to future benefits2012-10-010
Total of all active and inactive participants2012-10-01185
2011: WINTERGREEN FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-10-01203
Total number of active participants reported on line 7a of the Form 55002011-10-01210
Number of retired or separated participants receiving benefits2011-10-010
Number of other retired or separated participants entitled to future benefits2011-10-010
Total of all active and inactive participants2011-10-01210
2010: WINTERGREEN FLEXIBLE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-10-01206
Total number of active participants reported on line 7a of the Form 55002010-10-01203
Number of retired or separated participants receiving benefits2010-10-010
Number of other retired or separated participants entitled to future benefits2010-10-010
Total of all active and inactive participants2010-10-01203
2009: WINTERGREEN FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-10-01260
Total number of active participants reported on line 7a of the Form 55002009-10-01278
Number of retired or separated participants receiving benefits2009-10-010
Number of other retired or separated participants entitled to future benefits2009-10-010
Total of all active and inactive participants2009-10-01278

Form 5500 Responses for WINTERGREEN FLEXIBLE BENEFITS PLAN

2015: WINTERGREEN FLEXIBLE BENEFITS PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan funding arrangement – General assets of the sponsorYes
2015-10-01Plan benefit arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – General assets of the sponsorYes
2014: WINTERGREEN FLEXIBLE BENEFITS PLAN 2014 form 5500 responses
2014-10-01Type of plan entitySingle employer plan
2014-10-01Submission has been amendedNo
2014-10-01This submission is the final filingNo
2014-10-01This return/report is a short plan year return/report (less than 12 months)No
2014-10-01Plan is a collectively bargained planNo
2014-10-01Plan funding arrangement – InsuranceYes
2014-10-01Plan funding arrangement – General assets of the sponsorYes
2014-10-01Plan benefit arrangement – InsuranceYes
2014-10-01Plan benefit arrangement – General assets of the sponsorYes
2013: WINTERGREEN FLEXIBLE BENEFITS PLAN 2013 form 5500 responses
2013-10-01Type of plan entitySingle employer plan
2013-10-01Submission has been amendedNo
2013-10-01This submission is the final filingNo
2013-10-01This return/report is a short plan year return/report (less than 12 months)No
2013-10-01Plan is a collectively bargained planNo
2013-10-01Plan funding arrangement – InsuranceYes
2013-10-01Plan benefit arrangement – InsuranceYes
2012: WINTERGREEN FLEXIBLE BENEFITS PLAN 2012 form 5500 responses
2012-10-01Type of plan entitySingle employer plan
2012-10-01Submission has been amendedYes
2012-10-01This submission is the final filingNo
2012-10-01This return/report is a short plan year return/report (less than 12 months)No
2012-10-01Plan is a collectively bargained planNo
2012-10-01Plan funding arrangement – InsuranceYes
2012-10-01Plan benefit arrangement – InsuranceYes
2011: WINTERGREEN FLEXIBLE BENEFITS PLAN 2011 form 5500 responses
2011-10-01Type of plan entitySingle employer plan
2011-10-01Submission has been amendedYes
2011-10-01This submission is the final filingNo
2011-10-01This return/report is a short plan year return/report (less than 12 months)No
2011-10-01Plan is a collectively bargained planNo
2011-10-01Plan funding arrangement – InsuranceYes
2011-10-01Plan benefit arrangement – InsuranceYes
2010: WINTERGREEN FLEXIBLE BENEFITS PLAN 2010 form 5500 responses
2010-10-01Type of plan entitySingle employer plan
2010-10-01Submission has been amendedYes
2010-10-01This submission is the final filingNo
2010-10-01This return/report is a short plan year return/report (less than 12 months)No
2010-10-01Plan is a collectively bargained planNo
2010-10-01Plan funding arrangement – InsuranceYes
2010-10-01Plan funding arrangement – General assets of the sponsorYes
2010-10-01Plan benefit arrangement – InsuranceYes
2010-10-01Plan benefit arrangement – General assets of the sponsorYes
2009: WINTERGREEN FLEXIBLE BENEFITS PLAN 2009 form 5500 responses
2009-10-01Type of plan entitySingle employer plan
2009-10-01Submission has been amendedNo
2009-10-01This submission is the final filingNo
2009-10-01This return/report is a short plan year return/report (less than 12 months)No
2009-10-01Plan is a collectively bargained planNo
2009-10-01Plan funding arrangement – InsuranceYes
2009-10-01Plan funding arrangement – General assets of the sponsorYes
2009-10-01Plan benefit arrangement – InsuranceYes
2009-10-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number865152
Policy instance 2
Insurance contract or identification number865152
Number of Individuals Covered227
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $9,434
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $72,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,394
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract numberB4JXP/452153
Policy instance 3
Insurance contract or identification numberB4JXP/452153
Number of Individuals Covered172
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $5,848
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $215,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,848
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )
Policy contract numberB4JXP
Policy instance 1
Insurance contract or identification numberB4JXP
Number of Individuals Covered263
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $18,793
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,223,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,793
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number600347
Policy instance 2
Insurance contract or identification number600347
Number of Individuals Covered247
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $3,794
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,794
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )
Policy contract numberB4JXP
Policy instance 3
Insurance contract or identification numberB4JXP
Number of Individuals Covered187
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $28,265
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,292,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,265
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number865152
Policy instance 1
Insurance contract or identification number865152
Number of Individuals Covered242
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $8,165
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $62,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,165
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number600347
Policy instance 4
Insurance contract or identification number600347
Number of Individuals Covered269
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $3,793
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,793
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number865152
Policy instance 3
Insurance contract or identification number865152
Number of Individuals Covered248
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $7,668
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $63,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,668
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 )
Policy contract numberB4JXP
Policy instance 2
Insurance contract or identification numberB4JXP
Number of Individuals Covered294
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $27,387
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,635,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,387
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number800232
Policy instance 1
Insurance contract or identification number800232
Number of Individuals Covered1
Insurance policy start date2012-10-11
Insurance policy end date2013-10-10
Total amount of commissions paid to insurance brokerUSD $43
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number373289
Policy instance 6
Insurance contract or identification number373289
Number of Individuals Covered10
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $1,280
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $8,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,274
Insurance broker organization code?3
Insurance broker nameCOMMONWEALTH PLANNING, LLC
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number302107 ET AL
Policy instance 2
Insurance contract or identification number302107 ET AL
Number of Individuals Covered1
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $208
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $10,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $208
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number800232
Policy instance 3
Insurance contract or identification number800232
Number of Individuals Covered2
Insurance policy start date2011-10-11
Insurance policy end date2012-10-10
Total amount of commissions paid to insurance brokerUSD $118
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $2,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $118
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number846583 ET AL
Policy instance 4
Insurance contract or identification number846583 ET AL
Number of Individuals Covered327
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $7,599
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $95,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $7,599
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number42-1899-03
Policy instance 5
Insurance contract or identification number42-1899-03
Number of Individuals Covered91
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $4,702
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $55,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number855921G
Policy instance 6
Insurance contract or identification number855921G
Number of Individuals Covered83
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $3,631
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $21,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 )
Policy contract number302107 ET AL
Policy instance 1
Insurance contract or identification number302107 ET AL
Number of Individuals Covered343
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $28,406
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,433,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,406
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number373289
Policy instance 7
Insurance contract or identification number373289
Number of Individuals Covered10
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $1,280
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $8,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number42189903
Policy instance 8
Insurance contract or identification number42189903
Number of Individuals Covered0
Insurance policy start date2013-07-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $899
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $15,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $899
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number42189903
Policy instance 7
Insurance contract or identification number42189903
Number of Individuals Covered0
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $4,921
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $56,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,921
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number855921G
Policy instance 5
Insurance contract or identification number855921G
Number of Individuals Covered83
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $3,631
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $21,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,631
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number213346
Policy instance 8
Insurance contract or identification number213346
Number of Individuals Covered66
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $4,767
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $46,140
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 number855921G
Policy instance 5
Insurance contract or identification number855921G
Number of Individuals Covered86
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $3,388
Total amount of fees paid to insurance companyUSD $487
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $22,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 )
Policy contract number302107 ET AL
Policy instance 1
Insurance contract or identification number302107 ET AL
Number of Individuals Covered321
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $23,596
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,179,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number302107 ET AL
Policy instance 2
Insurance contract or identification number302107 ET AL
Number of Individuals Covered17
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $1,122
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $56,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number42189903
Policy instance 6
Insurance contract or identification number42189903
Number of Individuals Covered0
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $4,363
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $55,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number846583 ET AL
Policy instance 4
Insurance contract or identification number846583 ET AL
Number of Individuals Covered359
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $7,150
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $97,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number800232
Policy instance 3
Insurance contract or identification number800232
Number of Individuals Covered2
Insurance policy start date2010-10-11
Insurance policy end date2011-10-10
Total amount of commissions paid to insurance brokerUSD $237
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $2,941
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 number373289
Policy instance 7
Insurance contract or identification number373289
Number of Individuals Covered11
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $1,579
Total amount of fees paid to insurance companyUSD $759
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $10,473
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number42189903
Policy instance 7
Insurance contract or identification number42189903
Number of Individuals Covered0
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $5,285
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $91,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,285
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number373289
Policy instance 6
Insurance contract or identification number373289
Number of Individuals Covered12
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $1,619
Total amount of fees paid to insurance companyUSD $587
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $10,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,611
Amount paid for insurance broker fees587
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameWILLIAM E. COUNTS
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number855921G
Policy instance 5
Insurance contract or identification number855921G
Number of Individuals Covered104
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $3,532
Total amount of fees paid to insurance companyUSD $433
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $22,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,532
Amount paid for insurance broker fees433
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number846583 ET AL
Policy instance 4
Insurance contract or identification number846583 ET AL
Number of Individuals Covered333
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $7,736
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $96,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,736
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 )
Policy contract number302107 ET AL
Policy instance 2
Insurance contract or identification number302107 ET AL
Number of Individuals Covered16
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $1,340
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $67,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,340
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 )
Policy contract number302107 ET AL
Policy instance 1
Insurance contract or identification number302107 ET AL
Number of Individuals Covered339
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $23,461
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $11,173,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,461
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number800232
Policy instance 3
Insurance contract or identification number800232
Number of Individuals Covered3
Insurance policy start date2009-10-11
Insurance policy end date2010-10-10
Total amount of commissions paid to insurance brokerUSD $176
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $3,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $176
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC

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