APPLIED MEDICAL TECHNOLOGIES has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN
401k plan membership statisitcs for AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-12-01 | 163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-12-01 | 163 |
| Number of retired or separated participants receiving benefits | 2022-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-12-01 | 70 |
| Total of all active and inactive participants | 2022-12-01 | 233 |
| 2021: AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-01 | 156 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-01 | 158 |
| Number of retired or separated participants receiving benefits | 2021-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-12-01 | 72 |
| Total of all active and inactive participants | 2021-12-01 | 231 |
| 2020: AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 134 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 156 |
| Number of retired or separated participants receiving benefits | 2020-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-01 | 2 |
| Total of all active and inactive participants | 2020-12-01 | 159 |
| 2019: AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 142 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 131 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 131 |
| Number of employers contributing to the scheme | 2019-12-01 | 0 |
| 2022: AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-12-01 | Type of plan entity | Single employer plan |
| 2022-12-01 | Submission has been amended | No |
| 2022-12-01 | This submission is the final filing | No |
| 2022-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2022-12-01 | Plan is a collectively bargained plan | No |
| 2022-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Submission has been amended | No |
| 2021-12-01 | This submission is the final filing | No |
| 2021-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-12-01 | Plan is a collectively bargained plan | No |
| 2021-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | Submission has been amended | No |
| 2020-12-01 | This submission is the final filing | No |
| 2020-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-12-01 | Plan is a collectively bargained plan | No |
| 2020-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: AMT GROUP, INC. HEALTH & WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | First time form 5500 has been submitted | Yes |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDB0BMV9 |
| Policy instance | 4 |
| Insurance contract or identification number | GUDB0BMV9 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $451 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $451 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 707316 |
| Policy instance | 6 |
| Insurance contract or identification number | 707316 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SPECIFIED DISEASE | | 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? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BMV9 |
| Policy instance | 3 |
| Insurance contract or identification number | GUC 0BMV9 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $288 | | Total amount of fees paid to insurance company | USD $96 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,923 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 96 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BMV9 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0BMV9 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $122 | | Total amount of fees paid to insurance company | USD $122 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 81 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLLV0BMV9 |
| Policy instance | 1 |
| Insurance contract or identification number | GLLV0BMV9 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $77 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $77 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BMV9 |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0BMV9 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $209 | | Total amount of fees paid to insurance company | USD $70 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 70 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BMV9 |
| Policy instance | 2 |
| Insurance contract or identification number | GUC 0BMV9 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $3,365 | | Total amount of fees paid to insurance company | USD $1,121 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,860 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BMV9 |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0BMV9 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $2,454 | | Total amount of fees paid to insurance company | USD $818 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,360 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,086 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLLV0BMV9 |
| Policy instance | 4 |
| Insurance contract or identification number | GLLV0BMV9 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $928 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,283 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $928 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDB0BMV9 |
| Policy instance | 5 |
| Insurance contract or identification number | GUDB0BMV9 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $5,189 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $51,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,189 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BMV9 |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0BMV9 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $1,418 | | Total amount of fees paid to insurance company | USD $1,444 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,449 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,205 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 707316 |
| Policy instance | 6 |
| Insurance contract or identification number | 707316 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $2,202 | | Total amount of fees paid to insurance company | USD $294 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SPECIFIED DISEASE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,677 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,202 | | Amount paid for insurance broker fees | 294 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 23224 |
| Policy instance | 5 |
| Insurance contract or identification number | 23224 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $4,776 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $47,758 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,776 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT COMMISSIONS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BMV9 |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0BMV9 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $2,204 | | Total amount of fees paid to insurance company | USD $839 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,692 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,873 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BMV9 |
| Policy instance | 3 |
| Insurance contract or identification number | GUC 0BMV9 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $3,652 | | Total amount of fees paid to insurance company | USD $1,331 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,348 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,104 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BMV9 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0BMV9 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $1,315 | | Total amount of fees paid to insurance company | USD $1,331 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,766 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,118 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 14165050-1001 |
| Policy instance | 1 |
| Insurance contract or identification number | 14165050-1001 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $1,160 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,527 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,160 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT COMMISSIONS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BMV9 |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0BMV9 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $6,287 | | Total amount of fees paid to insurance company | USD $2,635 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $41,915 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 2616 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 5 |
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