P1 TECHNOLOGIES, INC. has sponsored the creation of one or more 401k plans.
Additional information about P1 TECHNOLOGIES, INC.
Submission information for form 5500 for 401k plan PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN
401k plan membership statisitcs for PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 252 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 252 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 252 |
| 2021: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 252 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 252 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 252 |
| 2020: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 261 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 261 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 261 |
| 2019: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 282 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 261 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 261 |
| 2018: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 277 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 282 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 282 |
| 2017: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 280 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 277 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 277 |
| 2016: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 289 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 280 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 280 |
| 2015: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 268 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 289 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 289 |
| 2014: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 273 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 268 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 268 |
| 2013: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 255 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 273 |
| Total of all active and inactive participants | 2013-01-01 | 273 |
| 2012: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 268 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 255 |
| Total of all active and inactive participants | 2012-01-01 | 255 |
| 2011: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 252 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 268 |
| Total of all active and inactive participants | 2011-01-01 | 268 |
| Total participants | 2011-01-01 | 268 |
| 2010: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 252 |
| Total of all active and inactive participants | 2010-01-01 | 252 |
| Total participants | 2010-01-01 | 252 |
| 2009: PLASTICS ONE, INC. FLEXIBLE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 241 |
| Total of all active and inactive participants | 2009-01-01 | 241 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0BX8B |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0BX8B | | Number of Individuals Covered | 69 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $1,525 | | Total amount of fees paid to insurance company | USD $274 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,525 | | Amount paid for insurance broker fees | 274 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 881389G |
| Policy instance | 1 |
| Insurance contract or identification number | 881389G | | Number of Individuals Covered | 252 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $849 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,989 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $849 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 0000060001 |
| Policy instance | 2 |
| Insurance contract or identification number | 0000060001 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $7,136 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,136 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BX8B |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BX8B | | Number of Individuals Covered | 277 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $1,190 | | Total amount of fees paid to insurance company | USD $198 | | Other welfare benefits provided | LIFE AND AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,190 | | Amount paid for insurance broker fees | 198 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0BX8B |
| Policy instance | 5 |
| Insurance contract or identification number | GUG 0BX8B | | Number of Individuals Covered | 270 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $3,147 | | Total amount of fees paid to insurance company | USD $501 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,474 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,147 | | Amount paid for insurance broker fees | 501 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BX8B |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0BX8B | | Number of Individuals Covered | 100 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $1,941 | | Total amount of fees paid to insurance company | USD $709 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,407 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,941 | | Amount paid for insurance broker fees | 709 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | L02989 |
| Policy instance | 7 |
| Insurance contract or identification number | L02989 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Welfare Benefit Premiums Paid to Carrier | USD $238,491 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | L02989 |
| Policy instance | 8 |
| Insurance contract or identification number | L02989 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,856 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 ) |
| Policy contract number | L02989 |
| Policy instance | 9 |
| Insurance contract or identification number | L02989 | | Number of Individuals Covered | 251 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $66,388 | | Other welfare benefits provided | HEALTH INDEMNITY | | Welfare Benefit Premiums Paid to Carrier | USD $1,418,159 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,388 | | Insurance broker organization code? | 3 |
|
| OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 ) |
| Policy contract number | 60777 |
| Policy instance | 3 |
| Insurance contract or identification number | 60777 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,939 | | Other welfare benefits provided | MEDICAL/HOSPITALIZATION | | Welfare Benefit Premiums Paid to Carrier | USD $146,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,939 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 2 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 383 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,423 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,423 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 881389G |
| Policy instance | 1 |
| Insurance contract or identification number | 881389G | | Number of Individuals Covered | 252 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $10,196 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,196 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 000099073133 |
| Policy instance | 4 |
| Insurance contract or identification number | 000099073133 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $214 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Insurance broker organization code? | 3 |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 |
| Policy instance | 5 |
| Insurance contract or identification number | 3204 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $25,889 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,289,941 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,889 | | Insurance broker organization code? | 3 |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 COBRA |
| Policy instance | 6 |
| Insurance contract or identification number | 3204 COBRA | | Number of Individuals Covered | 1 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 791599 |
| Policy instance | 7 |
| Insurance contract or identification number | 791599 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,938 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,938 | | Insurance broker organization code? | 3 |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3285 |
| Policy instance | 8 |
| Insurance contract or identification number | 3285 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $1,667 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,667 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 881389G |
| Policy instance | 1 |
| Insurance contract or identification number | 881389G | | Number of Individuals Covered | 252 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $10,196 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,196 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 2 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $6,271 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,271 | | Insurance broker organization code? | 3 |
|
| OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 ) |
| Policy contract number | 60777 |
| Policy instance | 3 |
| Insurance contract or identification number | 60777 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,939 | | Other welfare benefits provided | MEDICAL/HOSPITALIZATION | | Welfare Benefit Premiums Paid to Carrier | USD $146,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,939 | | Insurance broker organization code? | 3 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 000099073133 |
| Policy instance | 4 |
| Insurance contract or identification number | 000099073133 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $214 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Insurance broker organization code? | 3 |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 |
| Policy instance | 5 |
| Insurance contract or identification number | 3204 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $25,889 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,289,941 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,889 | | Insurance broker organization code? | 3 |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 COBRA |
| Policy instance | 6 |
| Insurance contract or identification number | 3204 COBRA | | Number of Individuals Covered | 1 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 791599 |
| Policy instance | 7 |
| Insurance contract or identification number | 791599 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,938 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,938 | | Insurance broker organization code? | 3 |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3285 |
| Policy instance | 8 |
| Insurance contract or identification number | 3285 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $1,667 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,667 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 791599 |
| Policy instance | 7 |
| Insurance contract or identification number | 791599 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,988 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,771 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,733 | | Insurance broker organization code? | 3 |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 COBRA |
| Policy instance | 6 |
| Insurance contract or identification number | 3204 COBRA | | Number of Individuals Covered | 1 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,522 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 |
| Policy instance | 5 |
| Insurance contract or identification number | 3204 | | Number of Individuals Covered | 367 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $33,255 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,657,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,255 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 000099073133 |
| Policy instance | 4 |
| Insurance contract or identification number | 000099073133 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-04-01 | | Total amount of commissions paid to insurance broker | USD $214 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Insurance broker organization code? | 3 |
|
| OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 ) |
| Policy contract number | 60777 |
| Policy instance | 3 |
| Insurance contract or identification number | 60777 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,984 | | Other welfare benefits provided | MEDICAL/HOSPITALIZATION | | Welfare Benefit Premiums Paid to Carrier | USD $299,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,984 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 2 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 455 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $9,145 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,145 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 881389G |
| Policy instance | 1 |
| Insurance contract or identification number | 881389G | | Number of Individuals Covered | 261 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $8,893 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $97,518 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,893 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 791599 |
| Policy instance | 7 |
| Insurance contract or identification number | 791599 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,477 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,056 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,402 | | Insurance broker organization code? | 3 |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 COBRA |
| Policy instance | 6 |
| Insurance contract or identification number | 3204 COBRA | | Number of Individuals Covered | 1 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,418 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 |
| Policy instance | 5 |
| Insurance contract or identification number | 3204 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $34,212 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,705,159 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,212 |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 000099073133 |
| Policy instance | 4 |
| Insurance contract or identification number | 000099073133 | | Number of Individuals Covered | 282 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-04-01 | | Total amount of commissions paid to insurance broker | USD $214 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Insurance broker organization code? | 3 |
|
| OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 ) |
| Policy contract number | 60777 |
| Policy instance | 3 |
| Insurance contract or identification number | 60777 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $5,136 | | Other welfare benefits provided | MEDICAL/HOSPITALIZATION | | Welfare Benefit Premiums Paid to Carrier | USD $256,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,136 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 2 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 454 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $8,763 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,763 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 881389G |
| Policy instance | 1 |
| Insurance contract or identification number | 881389G | | Number of Individuals Covered | 282 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $9,964 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,998 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,633 | | Insurance broker organization code? | 3 |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 41442000V |
| Policy instance | 1 |
| Insurance contract or identification number | 41442000V | | Number of Individuals Covered | 277 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $9,356 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $86,385 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,356 | | Insurance broker organization code? | 3 | | Insurance broker name | D & S LIFE AGENCY |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 2 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 471 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $8,831 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,831 | | Insurance broker organization code? | 3 | | Insurance broker name | D&S LIFE AGENCY INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | |
| Policy instance | 3 |
| Number of Individuals Covered | 14 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $238 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,378 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $238 | | Insurance broker organization code? | 3 | | Insurance broker name | D & S LIFE AGENCY INC |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 000099073133 |
| Policy instance | 4 |
| Insurance contract or identification number | 000099073133 | | Number of Individuals Covered | 280 | | Insurance policy start date | 2016-04-01 | | Insurance policy end date | 2017-04-01 | | Total amount of commissions paid to insurance broker | USD $232 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $214 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH AND MCLENNAN AGENCY |
|
| OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 ) |
| Policy contract number | 3204 |
| Policy instance | 5 |
| Insurance contract or identification number | 3204 | | Number of Individuals Covered | 431 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $33,849 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,692,464 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,849 | | Insurance broker name | D&S LIFE AGENCY INC |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 43573 |
| Policy instance | 1 |
| Insurance contract or identification number | 43573 | | Number of Individuals Covered | 380 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $41,130 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,452,312 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,130 | | Insurance broker organization code? | 3 | | Insurance broker name | D & S LIFE AGENCY INC |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 41442000V |
| Policy instance | 2 |
| Insurance contract or identification number | 41442000V | | Number of Individuals Covered | 289 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $9,538 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,995 | | Insurance broker organization code? | 3 | | Insurance broker name | D & S LIFE AGENCY |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 3 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 454 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $8,265 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $663 | | Insurance broker organization code? | 3 | | Insurance broker name | D&S LIFE AGENCY INC |
|
| HEALTHKEEPERS, INC (National Association of Insurance Commissioners NAIC id number: 95169 ) |
| Policy contract number | |
| Policy instance | 4 |
| Number of Individuals Covered | 42 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $213,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | D&S LIFE AGENCY INC |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 3 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 436 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,912 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,912 | | Insurance broker organization code? | 3 | | Insurance broker name | RUTHERFOORD FINANCIAL SERVICES INC |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 43573 |
| Policy instance | 1 |
| Insurance contract or identification number | 43573 | | Number of Individuals Covered | 418 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $36,668 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,675,141 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,668 | | Insurance broker organization code? | 3 | | Insurance broker name | RUTHERFOORD FINANCIAL SERVICES INC |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 41442000V |
| Policy instance | 2 |
| Insurance contract or identification number | 41442000V | | Number of Individuals Covered | 281 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $9,644 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,398 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,644 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS RUTHEROORD INC |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 4 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 427 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $8,215 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,215 | | Insurance broker organization code? | 3 | | Insurance broker name | RUTHERFOORD FINANCIAL SERVICES INC |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 41442000V |
| Policy instance | 3 |
| Insurance contract or identification number | 41442000V | | Number of Individuals Covered | 276 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $8,741 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,741 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS RUTHEROORD INC |
|
| SH-COVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 96555 ) |
| Policy contract number | 9320040000 |
| Policy instance | 2 |
| Insurance contract or identification number | 9320040000 | | Number of Individuals Covered | 427 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $48,447 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,614,915 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,447 | | Insurance broker organization code? | 3 | | Insurance broker name | RUTHERFOORD FINANCIAL SERVICES INC |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 43573 |
| Policy instance | 1 |
| Insurance contract or identification number | 43573 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,769 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,769 | | Insurance broker organization code? | 3 | | Insurance broker name | RUTHERFOORD FINANCIAL SERVICES INC |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 30792 |
| Policy instance | 5 |
| Insurance contract or identification number | 30792 | | Number of Individuals Covered | 396 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,510 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,348 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,510 | | Insurance broker organization code? | 3 | | Insurance broker name | RUTHERFORD FINANCIAL SERVICES |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | 43573 |
| Policy instance | 1 |
| Insurance contract or identification number | 43573 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $29,746 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,487,429 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22 | | Insurance broker organization code? | 3 | | Insurance broker name | RUTHERFOORD FINANCIAL SVCS INC |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 43887000A |
| Policy instance | 2 |
| Insurance contract or identification number | 43887000A | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $391 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $391 | | Insurance broker organization code? | 3 | | Insurance broker name | DIGITAL INSURANCE INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0402768 |
| Policy instance | 4 |
| Insurance contract or identification number | R0402768 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $6,300 | | Total amount of fees paid to insurance company | USD $1,869 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $36,032 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,300 | | Amount paid for insurance broker fees | 1869 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 | | Insurance broker name | DIGITAL INSURANCE INC |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 3 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 446 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $7,394 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,179 | | Insurance broker organization code? | 3 | | Insurance broker name | DIGITAL INSURANCE INC |
|
| DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 ) |
| Policy contract number | 000600001 |
| Policy instance | 3 |
| Insurance contract or identification number | 000600001 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $7,000 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | 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 | 43573 |
| Policy instance | 1 |
| Insurance contract or identification number | 43573 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $30,783 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,539,143 | | 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 | 43887000A |
| Policy instance | 2 |
| Insurance contract or identification number | 43887000A | | Number of Individuals Covered | 268 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $7,562 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,471 | | 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 | 41442 |
| Policy instance | 1 |
| Insurance contract or identification number | 41442 | | Number of Individuals Covered | 228 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $30,438 | | Total amount of fees paid to insurance company | USD $1,392 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,438 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1392 | | Additional information about fees paid to insurance broker | INCENTIVES, EDUCATION, COMMUNICATION & TRAINING | | Insurance broker name | THOMAS RUTHERFOORD INC. |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 01411000V |
| Policy instance | 2 |
| Insurance contract or identification number | 01411000V | | Number of Individuals Covered | 252 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $7,443 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,443 | | Insurance broker organization code? | 3 | | Insurance broker name | RUTHERFOORD FINANCIAL SERVICES INC |
|
