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FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 401k Plan overview

Plan NameFIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN
Plan identification number 502

FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

FIRST COMMUNITY BANCSHARES, INC. has sponsored the creation of one or more 401k plans.

Company Name:FIRST COMMUNITY BANCSHARES, INC.
Employer identification number (EIN):550694814
NAIC Classification:522110
NAIC Description:Commercial Banking

Additional information about FIRST COMMUNITY BANCSHARES, INC.

Jurisdiction of Incorporation: Nevada Department of State
Incorporation Date: 1997-07-28
Company Identification Number: 19971230456
Legal Registered Office Address: 2215-B RENAISSANCE DR

LAS VEGAS
United States of America (USA)
89119

More information about FIRST COMMUNITY BANCSHARES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01MELISSA BAILEY2023-09-29
5022021-01-01
5022020-01-01MELISSA BAILEY2021-10-12
5022019-01-01MELISSA WARD2020-10-14
5022018-01-01MELISSA WARD2019-09-03
5022017-01-01
5022016-01-01MELISSA WARD, SPHR
5022015-01-01MELISSA WARD, SPHR
5022014-01-01MELISSA WARD, SPHR
5022013-01-01JUDITH N. SWEGER
5022012-01-01JUDITH N. SWEGER
5022011-01-01JUDITH N. SWEGER JUDITH N. SWEGER2012-06-14
5022010-01-01JUDITH N. SWEGER JUDITH N. SWEGER2011-05-20
5022009-01-01JUDY SWEGER,HUMAN RESOURCE DIRECTOR

Plan Statistics for FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN

401k plan membership statisitcs for FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN

Measure Date Value
2022: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01627
Total number of active participants reported on line 7a of the Form 55002022-01-01631
Number of retired or separated participants receiving benefits2022-01-012
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01633
2021: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01643
Total number of active participants reported on line 7a of the Form 55002021-01-01625
Number of retired or separated participants receiving benefits2021-01-012
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01627
2020: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01526
Total number of active participants reported on line 7a of the Form 55002020-01-01638
Number of retired or separated participants receiving benefits2020-01-015
Total of all active and inactive participants2020-01-01643
2019: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01536
Total number of active participants reported on line 7a of the Form 55002019-01-01526
Total of all active and inactive participants2019-01-01526
2018: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01580
Total number of active participants reported on line 7a of the Form 55002018-01-01536
Total of all active and inactive participants2018-01-01536
2017: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01618
Total number of active participants reported on line 7a of the Form 55002017-01-01580
Total of all active and inactive participants2017-01-01580
2016: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01714
Total number of active participants reported on line 7a of the Form 55002016-01-01602
Number of retired or separated participants receiving benefits2016-01-0116
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01618
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2016-01-010
2015: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01712
Total number of active participants reported on line 7a of the Form 55002015-01-01694
Number of retired or separated participants receiving benefits2015-01-0120
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01714
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2015-01-010
2014: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01769
Total number of active participants reported on line 7a of the Form 55002014-01-01691
Number of retired or separated participants receiving benefits2014-01-0121
Total of all active and inactive participants2014-01-01712
2013: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01794
Total number of active participants reported on line 7a of the Form 55002013-01-01744
Number of retired or separated participants receiving benefits2013-01-0125
Total of all active and inactive participants2013-01-01769
2012: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01677
Total number of active participants reported on line 7a of the Form 55002012-01-01765
Number of retired or separated participants receiving benefits2012-01-0129
Total of all active and inactive participants2012-01-01794
2011: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01771
Total number of active participants reported on line 7a of the Form 55002011-01-01646
Number of retired or separated participants receiving benefits2011-01-0131
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01677
2010: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01761
Total number of active participants reported on line 7a of the Form 55002010-01-01737
Number of retired or separated participants receiving benefits2010-01-0134
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-01771
2009: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01722
Total number of active participants reported on line 7a of the Form 55002009-01-01721
Number of retired or separated participants receiving benefits2009-01-0140
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01761
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-01-010

Financial Data on FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN

Measure Date Value
2017 : FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2017 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-12-31No
Was this plan covered by a fidelity bond2017-12-31No
If this is an individual account plan, was there a blackout period2017-12-31No
Were there any nonexempt tranactions with any party-in-interest2017-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-12-31No
Were any leases to which the plan was party in default or uncollectible2017-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-12-31No
Was there a failure to transmit to the plan any participant contributions2017-12-31No
Has the plan failed to provide any benefit when due under the plan2017-12-31No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32017-12-31No
Did the plan have assets held for investment2017-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-12-31No

Form 5500 Responses for FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN

2022: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedYes
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: FIRST COMMUNITY BANCSHARES, INC. LIFE, ACCIDENTAL DEATH & DISMEMBERMENT & LONG TERM DISABILITY PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BD7K
Policy instance 5
Insurance contract or identification numberG000BD7K
Number of Individuals Covered244
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $11,383
Total amount of fees paid to insurance companyUSD $2,174
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $103,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,383
Amount paid for insurance broker fees2174
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BD7K
Policy instance 4
Insurance contract or identification numberG000BD7K
Number of Individuals Covered190
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $7,392
Total amount of fees paid to insurance companyUSD $1,349
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 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 $73,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,392
Amount paid for insurance broker fees1349
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000BD7K
Policy instance 3
Insurance contract or identification numberG000BD7K
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $141
Total amount of fees paid to insurance companyUSD $28
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $141
Amount paid for insurance broker fees28
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BD7K
Policy instance 2
Insurance contract or identification numberG000BD7K
Number of Individuals Covered613
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $14,387
Total amount of fees paid to insurance companyUSD $2,860
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $130,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,387
Amount paid for insurance broker fees2860
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BD7K
Policy instance 1
Insurance contract or identification numberG000BD7K
Number of Individuals Covered607
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $12,045
Total amount of fees paid to insurance companyUSD $1,769
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $100,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,045
Amount paid for insurance broker fees1769
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BD7K
Policy instance 4
Insurance contract or identification numberG000BD7K
Number of Individuals Covered244
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $10,636
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $96,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,636
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BD7K
Policy instance 3
Insurance contract or identification numberG000BD7K
Number of Individuals Covered185
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,685
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $66,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,685
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BD7K
Policy instance 2
Insurance contract or identification numberG000BD7K
Number of Individuals Covered618
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $13,135
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $119,406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,135
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BD7K
Policy instance 1
Insurance contract or identification numberG000BD7K
Number of Individuals Covered601
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $10,979
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $91,494
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,979
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number52767
Policy instance 1
Insurance contract or identification number52767
Number of Individuals Covered643
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $54,524
Total amount of fees paid to insurance companyUSD $142
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D , VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $313,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,536
Insurance broker organization code?3
Amount paid for insurance broker fees126
Additional information about fees paid to insurance brokerTPA FEES
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number52767
Policy instance 1
Insurance contract or identification number52767
Number of Individuals Covered526
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $44,865
Total amount of fees paid to insurance companyUSD $187
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D , VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $268,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,283
Insurance broker organization code?3
Amount paid for insurance broker fees187
Additional information about fees paid to insurance brokerTPA FEES
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number52767
Policy instance 1
Insurance contract or identification number52767
Number of Individuals Covered580
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $46,872
Total amount of fees paid to insurance companyUSD $193
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D , VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $569,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,465
Insurance broker organization code?3
Amount paid for insurance broker fees193
Additional information about fees paid to insurance brokerADMINISTRATIVE FEE
Insurance broker nameAXA ASSISTANCE, USA

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