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FIRST COMMUNITY BANK CAFETERIA PLAN 401k Plan overview

Plan NameFIRST COMMUNITY BANK CAFETERIA PLAN
Plan identification number 505

FIRST COMMUNITY BANK CAFETERIA PLAN Benefits

401k Plan Type
Plan Features/Benefits

    401k Sponsoring company profile

    FIRST COMMUNITY BANK has sponsored the creation of one or more 401k plans.

    Company Name:FIRST COMMUNITY BANK
    Employer identification number (EIN):571030051
    NAIC Classification:522110
    NAIC Description:Commercial Banking

    Form 5500 Filing Information

    Submission information for form 5500 for 401k plan FIRST COMMUNITY BANK CAFETERIA PLAN

    Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
    5052021-01-01BROOKE KUCHENBROD2022-07-25 BROOKE KUCHENBROD2022-07-25
    5052020-01-01BROOKE KUCHENBROD2021-07-16 BROOKE KUCHENBROD2021-07-16
    5052019-01-01BROOKE KUCHENBROD2020-06-15 BROOKE KUCHENBROD2020-06-15
    5052018-01-01
    5052017-01-01
    5052016-01-01
    5052015-01-01
    5052014-01-01
    5052013-01-01
    5052012-01-01MENDEL BOYKIN
    5052011-01-01MENDEL BOYKIN MENDEL BOYKIN2012-07-30
    5052010-01-01MENDEL BOYKIN MENDEL BOYKIN2011-09-13
    5052009-01-01SUSAN BOATWRIGHT SUSAN BOATWRIGHT2010-07-27

    Plan Statistics for FIRST COMMUNITY BANK CAFETERIA PLAN

    401k plan membership statisitcs for FIRST COMMUNITY BANK CAFETERIA PLAN

    Measure Date Value
    2021: FIRST COMMUNITY BANK CAFETERIA PLAN 2021 401k membership
    Total participants, beginning-of-year2021-01-01238
    Total number of active participants reported on line 7a of the Form 55002021-01-01242
    Total of all active and inactive participants2021-01-01242
    Total participants2021-01-01242
    2020: FIRST COMMUNITY BANK CAFETERIA PLAN 2020 401k membership
    Total participants, beginning-of-year2020-01-01280
    Total number of active participants reported on line 7a of the Form 55002020-01-01238
    Total of all active and inactive participants2020-01-01238
    Total participants2020-01-01238
    2019: FIRST COMMUNITY BANK CAFETERIA PLAN 2019 401k membership
    Total participants, beginning-of-year2019-01-01243
    Total number of active participants reported on line 7a of the Form 55002019-01-01280
    Total of all active and inactive participants2019-01-01280
    Total participants2019-01-01280
    2018: FIRST COMMUNITY BANK CAFETERIA PLAN 2018 401k membership
    Total participants, beginning-of-year2018-01-01235
    Total number of active participants reported on line 7a of the Form 55002018-01-01243
    Total of all active and inactive participants2018-01-01243
    Total participants2018-01-01243
    2017: FIRST COMMUNITY BANK CAFETERIA PLAN 2017 401k membership
    Total participants, beginning-of-year2017-01-01203
    Total number of active participants reported on line 7a of the Form 55002017-01-01235
    Total of all active and inactive participants2017-01-01235
    Total participants2017-01-01235
    2016: FIRST COMMUNITY BANK CAFETERIA PLAN 2016 401k membership
    Total participants, beginning-of-year2016-01-01190
    Total number of active participants reported on line 7a of the Form 55002016-01-01203
    Total of all active and inactive participants2016-01-01203
    Total participants2016-01-01203
    2015: FIRST COMMUNITY BANK CAFETERIA PLAN 2015 401k membership
    Total participants, beginning-of-year2015-01-01190
    Total number of active participants reported on line 7a of the Form 55002015-01-01190
    Number of retired or separated participants receiving benefits2015-01-010
    Number of other retired or separated participants entitled to future benefits2015-01-010
    Total of all active and inactive participants2015-01-01190
    Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2015-01-010
    Total participants2015-01-01190
    Number of participants with account balances2015-01-010
    Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2015-01-010
    Number of employers contributing to the scheme2015-01-010
    2014: FIRST COMMUNITY BANK CAFETERIA PLAN 2014 401k membership
    Total participants, beginning-of-year2014-01-01185
    Total number of active participants reported on line 7a of the Form 55002014-01-01185
    Number of retired or separated participants receiving benefits2014-01-010
    Number of other retired or separated participants entitled to future benefits2014-01-010
    Total of all active and inactive participants2014-01-01185
    Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2014-01-010
    Total participants2014-01-01185
    Number of participants with account balances2014-01-010
    Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2014-01-010
    2013: FIRST COMMUNITY BANK CAFETERIA PLAN 2013 401k membership
    Total participants, beginning-of-year2013-01-01151
    Total number of active participants reported on line 7a of the Form 55002013-01-01154
    Number of retired or separated participants receiving benefits2013-01-010
    Number of other retired or separated participants entitled to future benefits2013-01-010
    Total of all active and inactive participants2013-01-01154
    Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2013-01-010
    Total participants2013-01-01154
    Number of participants with account balances2013-01-010
    Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2013-01-010
    2012: FIRST COMMUNITY BANK CAFETERIA PLAN 2012 401k membership
    Total participants, beginning-of-year2012-01-01153
    Total number of active participants reported on line 7a of the Form 55002012-01-01151
    Total of all active and inactive participants2012-01-01151
    Total participants2012-01-01151
    2011: FIRST COMMUNITY BANK CAFETERIA PLAN 2011 401k membership
    Total participants, beginning-of-year2011-01-01139
    Total number of active participants reported on line 7a of the Form 55002011-01-01153
    Total of all active and inactive participants2011-01-01153
    Total participants2011-01-01153
    2010: FIRST COMMUNITY BANK CAFETERIA PLAN 2010 401k membership
    Total participants, beginning-of-year2010-01-01135
    Total number of active participants reported on line 7a of the Form 55002010-01-01139
    Total of all active and inactive participants2010-01-01139
    Total participants2010-01-01139
    2009: FIRST COMMUNITY BANK CAFETERIA PLAN 2009 401k membership
    Total participants, beginning-of-year2009-01-01140
    Total number of active participants reported on line 7a of the Form 55002009-01-01135
    Number of retired or separated participants receiving benefits2009-01-010
    Number of other retired or separated participants entitled to future benefits2009-01-010
    Total of all active and inactive participants2009-01-01135
    Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-01-010
    Total participants2009-01-01135
    Number of participants with account balances2009-01-010
    Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2009-01-010

    Form 5500 Responses for FIRST COMMUNITY BANK CAFETERIA PLAN

    2021: FIRST COMMUNITY BANK CAFETERIA PLAN 2021 form 5500 responses
    2021-01-01Type of plan entitySingle employer plan
    2021-01-01Submission has been amendedNo
    2021-01-01This submission is the final filingNo
    2021-01-01This return/report is a short plan year return/report (less than 12 months)No
    2021-01-01Plan is a collectively bargained planNo
    2021-01-01Plan funding arrangement – InsuranceYes
    2021-01-01Plan funding arrangement – General assets of the sponsorYes
    2021-01-01Plan benefit arrangement – InsuranceYes
    2021-01-01Plan benefit arrangement – General assets of the sponsorYes
    2020: FIRST COMMUNITY BANK CAFETERIA PLAN 2020 form 5500 responses
    2020-01-01Type of plan entitySingle employer plan
    2020-01-01Submission has been amendedNo
    2020-01-01This submission is the final filingNo
    2020-01-01This return/report is a short plan year return/report (less than 12 months)No
    2020-01-01Plan is a collectively bargained planNo
    2020-01-01Plan funding arrangement – InsuranceYes
    2020-01-01Plan funding arrangement – General assets of the sponsorYes
    2020-01-01Plan benefit arrangement – InsuranceYes
    2020-01-01Plan benefit arrangement – General assets of the sponsorYes
    2019: FIRST COMMUNITY BANK CAFETERIA PLAN 2019 form 5500 responses
    2019-01-01Type of plan entitySingle employer plan
    2019-01-01Submission has been amendedNo
    2019-01-01This submission is the final filingNo
    2019-01-01This return/report is a short plan year return/report (less than 12 months)No
    2019-01-01Plan is a collectively bargained planNo
    2019-01-01Plan funding arrangement – InsuranceYes
    2019-01-01Plan funding arrangement – General assets of the sponsorYes
    2019-01-01Plan benefit arrangement – InsuranceYes
    2019-01-01Plan benefit arrangement – General assets of the sponsorYes
    2018: FIRST COMMUNITY BANK CAFETERIA PLAN 2018 form 5500 responses
    2018-01-01Type of plan entitySingle employer plan
    2018-01-01Submission has been amendedNo
    2018-01-01This submission is the final filingNo
    2018-01-01This return/report is a short plan year return/report (less than 12 months)No
    2018-01-01Plan is a collectively bargained planNo
    2018-01-01Plan funding arrangement – InsuranceYes
    2018-01-01Plan funding arrangement – General assets of the sponsorYes
    2018-01-01Plan benefit arrangement – InsuranceYes
    2018-01-01Plan benefit arrangement – General assets of the sponsorYes
    2017: FIRST COMMUNITY BANK CAFETERIA PLAN 2017 form 5500 responses
    2017-01-01Type of plan entitySingle employer plan
    2017-01-01Submission has been amendedNo
    2017-01-01This submission is the final filingNo
    2017-01-01This return/report is a short plan year return/report (less than 12 months)No
    2017-01-01Plan is a collectively bargained planNo
    2017-01-01Plan funding arrangement – InsuranceYes
    2017-01-01Plan funding arrangement – General assets of the sponsorYes
    2017-01-01Plan benefit arrangement – InsuranceYes
    2017-01-01Plan benefit arrangement – General assets of the sponsorYes
    2016: FIRST COMMUNITY BANK CAFETERIA 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 funding arrangement – General assets of the sponsorYes
    2016-01-01Plan benefit arrangement – InsuranceYes
    2016-01-01Plan benefit arrangement – General assets of the sponsorYes
    2015: FIRST COMMUNITY BANK CAFETERIA 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 funding arrangement – General assets of the sponsorYes
    2015-01-01Plan benefit arrangement – InsuranceYes
    2015-01-01Plan benefit arrangement – General assets of the sponsorYes
    2014: FIRST COMMUNITY BANK CAFETERIA PLAN 2014 form 5500 responses
    2014-01-01Type of plan entitySingle employer plan
    2014-01-01Plan funding arrangement – InsuranceYes
    2014-01-01Plan funding arrangement – General assets of the sponsorYes
    2014-01-01Plan benefit arrangement – InsuranceYes
    2014-01-01Plan benefit arrangement – General assets of the sponsorYes
    2013: FIRST COMMUNITY BANK CAFETERIA PLAN 2013 form 5500 responses
    2013-01-01Type of plan entitySingle employer plan
    2013-01-01Plan funding arrangement – InsuranceYes
    2013-01-01Plan funding arrangement – General assets of the sponsorYes
    2013-01-01Plan benefit arrangement – InsuranceYes
    2013-01-01Plan benefit arrangement – General assets of the sponsorYes
    2012: FIRST COMMUNITY BANK CAFETERIA PLAN 2012 form 5500 responses
    2012-01-01Type of plan entitySingle employer plan
    2012-01-01Submission has been amendedNo
    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 funding arrangement – General assets of the sponsorYes
    2012-01-01Plan benefit arrangement – InsuranceYes
    2012-01-01Plan benefit arrangement – General assets of the sponsorYes
    2011: FIRST COMMUNITY BANK CAFETERIA PLAN 2011 form 5500 responses
    2011-01-01Type of plan entitySingle employer plan
    2011-01-01Plan funding arrangement – InsuranceYes
    2011-01-01Plan funding arrangement – General assets of the sponsorYes
    2011-01-01Plan benefit arrangement – InsuranceYes
    2011-01-01Plan benefit arrangement – General assets of the sponsorYes
    2010: FIRST COMMUNITY BANK CAFETERIA PLAN 2010 form 5500 responses
    2010-01-01Type of plan entitySingle employer plan
    2010-01-01Plan funding arrangement – InsuranceYes
    2010-01-01Plan funding arrangement – General assets of the sponsorYes
    2010-01-01Plan benefit arrangement – InsuranceYes
    2010-01-01Plan benefit arrangement – General assets of the sponsorYes
    2009: FIRST COMMUNITY BANK CAFETERIA PLAN 2009 form 5500 responses
    2009-01-01Type of plan entitySingle employer plan
    2009-01-01Plan funding arrangement – InsuranceYes
    2009-01-01Plan funding arrangement – General assets of the sponsorYes
    2009-01-01Plan benefit arrangement – InsuranceYes
    2009-01-01Plan benefit arrangement – General assets of the sponsorYes

    Insurance Providers Used on plan

    DELTA DENTAL OF MISSOURI (National Association of Insurance Commissioners NAIC id number: 55697 )
    Policy contract number22700000
    Policy instance 4
    Insurance contract or identification number22700000
    Number of Individuals Covered215
    Insurance policy start date2021-01-01
    Insurance policy end date2021-12-31
    Total amount of commissions paid to insurance brokerUSD $12,641
    Total amount of fees paid to insurance companyUSD $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 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
    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
    AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
    Policy contract numberG 00613018
    Policy instance 1
    Insurance contract or identification numberG 00613018
    Number of Individuals Covered242
    Insurance policy start date2021-01-01
    Insurance policy end date2021-12-31
    Total amount of commissions paid to insurance brokerUSD $37,091
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D, VOLUNTARY LIFE & AD&D, DEPENDENT LIFE & AD&D
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $247,271
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $37,091
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    PHYSICIANS EYECARE PLAN (National Association of Insurance Commissioners NAIC id number: 15447 )
    Policy contract number00217
    Policy instance 2
    Insurance contract or identification number00217
    Number of Individuals Covered169
    Insurance policy start date2021-01-01
    Insurance policy end date2021-12-31
    Total amount of commissions paid to insurance brokerUSD $2,349
    Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $23,494
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,349
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857
    Policy instance 3
    Insurance contract or identification number25-34857
    Number of Individuals Covered171
    Insurance policy start date2021-01-01
    Insurance policy end date2022-01-01
    Total amount of commissions paid to insurance brokerUSD $69,497
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $69,497
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    PHYSICIANS EYECARE PLAN (National Association of Insurance Commissioners NAIC id number: 15447 )
    Policy contract number00217
    Policy instance 2
    Insurance contract or identification number00217
    Number of Individuals Covered167
    Insurance policy start date2020-01-01
    Insurance policy end date2020-12-31
    Total amount of commissions paid to insurance brokerUSD $2,314
    Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $23,145
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,314
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857-00
    Policy instance 1
    Insurance contract or identification number25-34857-00
    Number of Individuals Covered172
    Insurance policy start date2020-01-01
    Insurance policy end date2021-01-01
    Total amount of commissions paid to insurance brokerUSD $71,460
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $71,460
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
    Policy contract numberG 00613018
    Policy instance 3
    Insurance contract or identification numberG 00613018
    Number of Individuals Covered238
    Insurance policy start date2020-01-01
    Insurance policy end date2020-12-31
    Total amount of commissions paid to insurance brokerUSD $34,558
    Total amount of fees paid to insurance companyUSD $6,594
    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 BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D, DEPENDENT LIFE, VOLUNTARY LIFE
    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 $230,390
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $34,558
    Amount paid for insurance broker fees6594
    Additional information about fees paid to insurance brokerPAID OVERRIDE COMMISSIONS
    Insurance broker organization code?3
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857-00
    Policy instance 2
    Insurance contract or identification number25-34857-00
    Number of Individuals Covered176
    Insurance policy start date2019-01-01
    Insurance policy end date2020-01-01
    Total amount of commissions paid to insurance brokerUSD $69,149
    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 BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $69,149
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    PHYSICIANS EYECARE PLAN (National Association of Insurance Commissioners NAIC id number: 15447 )
    Policy contract number00217
    Policy instance 3
    Insurance contract or identification number00217
    Number of Individuals Covered280
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $2,166
    Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $21,656
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,166
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
    Policy contract numberG 00613018
    Policy instance 1
    Insurance contract or identification numberG 00613018
    Number of Individuals Covered239
    Insurance policy start date2019-01-01
    Insurance policy end date2019-12-31
    Total amount of commissions paid to insurance brokerUSD $32,972
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D, DEPENDENT LIFE
    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 $219,814
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $32,972
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857-00
    Policy instance 1
    Insurance contract or identification number25-34857-00
    Number of Individuals Covered172
    Insurance policy start date2018-01-01
    Insurance policy end date2019-01-01
    Total amount of commissions paid to insurance brokerUSD $65,387
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $65,387
    Insurance broker organization code?3
    PHYSICIANS EYECARE PLAN (National Association of Insurance Commissioners NAIC id number: 15447 )
    Policy contract number00217
    Policy instance 2
    Insurance contract or identification number00217
    Number of Individuals Covered243
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $1,959
    Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $19,591
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,959
    Additional information about fees paid to insurance brokerCOMMISSIONS
    Insurance broker organization code?3
    AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
    Policy contract numberG 00613018
    Policy instance 3
    Insurance contract or identification numberG 00613018
    Number of Individuals Covered224
    Insurance policy start date2018-01-01
    Insurance policy end date2018-12-31
    Total amount of commissions paid to insurance brokerUSD $30,826
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D, DEPENDENT LIFE
    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 $205,505
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $30,826
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857-00
    Policy instance 1
    Insurance contract or identification number25-34857-00
    Number of Individuals Covered164
    Insurance policy start date2017-01-01
    Insurance policy end date2018-01-01
    Total amount of commissions paid to insurance brokerUSD $57,798
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $57,798
    Additional information about fees paid to insurance brokerCOMMISSIONS
    Insurance broker organization code?3
    Insurance broker nameCLARKE & COMPANY BENEFITS LLC
    PHYSICIANS EYECARE PLAN (National Association of Insurance Commissioners NAIC id number: 15447 )
    Policy contract number00217
    Policy instance 2
    Insurance contract or identification number00217
    Number of Individuals Covered235
    Insurance policy start date2017-01-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $18,475
    Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $18,475
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,847
    Additional information about fees paid to insurance brokerCOMMISSIONS
    Insurance broker organization code?3
    Insurance broker nameCLARKE & COMPANY BENEFITS LLC
    AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
    Policy contract numberG 00613018
    Policy instance 3
    Insurance contract or identification numberG 00613018
    Number of Individuals Covered216
    Insurance policy start date2017-01-01
    Insurance policy end date2017-12-31
    Total amount of commissions paid to insurance brokerUSD $38,718
    Total amount of fees paid to insurance companyUSD $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 planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D, DEPENDENT LIFE
    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 $184,370
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $27,656
    Amount paid for insurance broker fees11062
    Additional information about fees paid to insurance brokerOTHER COMPENSATION & COMMISSIONS
    Insurance broker organization code?3
    Insurance broker nameCLARKE & COMPANY BENEFITS LLC
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857-00
    Policy instance 1
    Insurance contract or identification number25-34857-00
    Number of Individuals Covered146
    Insurance policy start date2015-01-01
    Insurance policy end date2016-01-01
    Total amount of commissions paid to insurance brokerUSD $48,195
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    Are there contracts with allocated funds for group deferred annuity?No
    Are there contracts with allocated funds for types other than group deferred annuity or individual?No
    Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitYes
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $48,195
    Additional information about fees paid to insurance brokerCOMMISSIONS
    Insurance broker organization code?3
    Insurance broker nameCLARKE & COMPANY BENEFITS LLC
    AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
    Policy contract numberG 00613018
    Policy instance 3
    Insurance contract or identification numberG 00613018
    Number of Individuals Covered189
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $33,564
    Total amount of fees paid to insurance companyUSD $0
    Are there contracts with allocated funds for individual policies?No
    Are there contracts with allocated funds for group deferred annuity?No
    Are there contracts with allocated funds for types other than group deferred annuity or individual?No
    Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitNo
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitNo
    Other welfare benefits providedAD&D, DEP LIFE
    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 $149,174
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $22,376
    Amount paid for insurance broker fees11189
    Additional information about fees paid to insurance brokerOTHER COMPENSATION & COMMISSIONS
    Insurance broker organization code?3
    Insurance broker nameCLARKE & COMPANY BENEFITS
    PHYSICIANS EYECARE PLAN (National Association of Insurance Commissioners NAIC id number: 15447 )
    Policy contract number00217
    Policy instance 2
    Insurance contract or identification number00217
    Number of Individuals Covered190
    Insurance policy start date2015-01-01
    Insurance policy end date2015-12-31
    Total amount of commissions paid to insurance brokerUSD $1,621
    Are there contracts with allocated funds for individual policies?No
    Are there contracts with allocated funds for group deferred annuity?No
    Are there contracts with allocated funds for types other than group deferred annuity or individual?No
    Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
    Contracts With Unallocated Funds Deposit Administration0
    Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
    Are there contracts with unallocated funds for contracts of type guaranteed investment?No
    Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
    Health Insurance Welfare BenefitNo
    Dental Insurance Welfare BenefitNo
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitNo
    Temporary Disability Insurance Welfare BenefitNo
    Long Term Disability Insurance Welfare BenefitNo
    Unemployment Insurance Welfare BenefitNo
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Welfare Benefit Premiums Paid to CarrierUSD $16,215
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,621
    Additional information about fees paid to insurance brokerCOMMISSIONS
    Insurance broker organization code?3
    Insurance broker nameCLARKE & COMPANY BENEFITS LLC
    PHYSICIANS EYECARE PLAN (National Association of Insurance Commissioners NAIC id number: 15447 )
    Policy contract number00217
    Policy instance 2
    Insurance contract or identification number00217
    Number of Individuals Covered116
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $1,647
    Vision Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $16,479
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,647
    Amount paid for insurance broker fees0
    Additional information about fees paid to insurance brokerCOMMISSION
    Insurance broker organization code?3
    Insurance broker nameCLARKE & COMPANY BENEFITS LLC
    AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
    Policy contract numberG 00613018
    Policy instance 3
    Insurance contract or identification numberG 00613018
    Number of Individuals Covered185
    Insurance policy start date2014-01-01
    Insurance policy end date2014-12-31
    Total amount of commissions paid to insurance brokerUSD $33,404
    Total amount of fees paid to insurance companyUSD $0
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $148,460
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $22,269
    Amount paid for insurance broker fees11135
    Additional information about fees paid to insurance brokerOTHER COMPENSATION
    Insurance broker organization code?4
    Insurance broker nameCLARKE AND COMPANY BENEFITS
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857-00
    Policy instance 1
    Insurance contract or identification number25-34857-00
    Number of Individuals Covered145
    Insurance policy start date2014-01-01
    Insurance policy end date2015-01-01
    Total amount of commissions paid to insurance brokerUSD $47,915
    Total amount of fees paid to insurance companyUSD $0
    Health Insurance Welfare BenefitYes
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $47,915
    Amount paid for insurance broker fees0
    Additional information about fees paid to insurance brokerCOMMISSION
    Insurance broker organization code?3
    Insurance broker nameCLARKE & COMPANY BENEFITS LLC
    SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
    Policy contract number246-6592-00
    Policy instance 2
    Insurance contract or identification number246-6592-00
    Number of Individuals Covered154
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $8,747
    Total amount of fees paid to insurance companyUSD $0
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Other welfare benefits providedDEPENDENT LIFE
    Welfare Benefit Premiums Paid to CarrierUSD $160,029
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3,390
    Amount paid for insurance broker fees0
    Insurance broker nameDAVIS GARVIN
    NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
    Policy contract number29500
    Policy instance 3
    Insurance contract or identification number29500
    Number of Individuals Covered98
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $1,376
    Total amount of fees paid to insurance companyUSD $0
    Vision Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $9,812
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $688
    Amount paid for insurance broker fees0
    Insurance broker nameTHE ADAMSON GROUP, INC.
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857-00
    Policy instance 1
    Insurance contract or identification number25-34857-00
    Number of Individuals Covered131
    Insurance policy start date2013-01-01
    Insurance policy end date2013-12-31
    Total amount of commissions paid to insurance brokerUSD $31,228
    Total amount of fees paid to insurance companyUSD $0
    Health Insurance Welfare BenefitYes
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $18,819
    Amount paid for insurance broker fees0
    Insurance broker nameCLARKE & COMPANY BENEFITS LLC
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number25-34857-00
    Policy instance 1
    Insurance contract or identification number25-34857-00
    Number of Individuals Covered135
    Insurance policy start date2012-01-01
    Insurance policy end date2013-01-01
    Total amount of commissions paid to insurance brokerUSD $35,965
    Total amount of fees paid to insurance companyUSD $0
    Health Insurance Welfare BenefitYes
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $35,965
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    Insurance broker nameDAVIS-GARVIN AGENCY
    NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
    Policy contract number29500
    Policy instance 3
    Insurance contract or identification number29500
    Number of Individuals Covered100
    Insurance policy start date2012-01-01
    Insurance policy end date2012-12-31
    Total amount of commissions paid to insurance brokerUSD $1,422
    Total amount of fees paid to insurance companyUSD $0
    Vision Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $9,580
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $711
    Insurance broker organization code?3
    Insurance broker nameTHE ADAMSON GROUP INC.
    SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
    Policy contract number246-6592-00
    Policy instance 2
    Insurance contract or identification number246-6592-00
    Number of Individuals Covered151
    Insurance policy start date2012-01-01
    Insurance policy end date2013-01-01
    Total amount of commissions paid to insurance brokerUSD $8,447
    Total amount of fees paid to insurance companyUSD $0
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $147,710
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
    Policy contract number2466592
    Policy instance 2
    Insurance contract or identification number2466592
    Number of Individuals Covered153
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $8,143
    Total amount of fees paid to insurance companyUSD $0
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Other welfare benefits providedDEPEND LIFE
    Welfare Benefit Premiums Paid to CarrierUSD $129,458
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number2534857
    Policy instance 1
    Insurance contract or identification number2534857
    Number of Individuals Covered136
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $30,299
    Total amount of fees paid to insurance companyUSD $0
    Health Insurance Welfare BenefitYes
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
    Policy contract number29500
    Policy instance 3
    Insurance contract or identification number29500
    Number of Individuals Covered86
    Insurance policy start date2011-01-01
    Insurance policy end date2011-12-31
    Total amount of commissions paid to insurance brokerUSD $1,050
    Total amount of fees paid to insurance companyUSD $0
    Vision Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $8,316
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
    Policy contract number29500
    Policy instance 3
    Insurance contract or identification number29500
    Number of Individuals Covered72
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $864
    Total amount of fees paid to insurance companyUSD $0
    Vision Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $6,760
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $432
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    Insurance broker nameADAMSON GROUP
    SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
    Policy contract number2466592
    Policy instance 2
    Insurance contract or identification number2466592
    Number of Individuals Covered139
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $7,873
    Total amount of fees paid to insurance companyUSD $0
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Other welfare benefits providedDEPENDENT LIFE
    Welfare Benefit Premiums Paid to CarrierUSD $115,564
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $7,873
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    Insurance broker nameDAVIS GARVIN AGENCY
    BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 38520 )
    Policy contract number2534857
    Policy instance 1
    Insurance contract or identification number2534857
    Number of Individuals Covered135
    Insurance policy start date2010-01-01
    Insurance policy end date2010-12-31
    Total amount of commissions paid to insurance brokerUSD $26,580
    Total amount of fees paid to insurance companyUSD $0
    Health Insurance Welfare BenefitYes
    Were dividends or retroactive rate refunds paid in cash?No
    Were dividends or retroactive rate refunds paid as a credit?No
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $26,580
    Amount paid for insurance broker fees0
    Insurance broker organization code?3
    Insurance broker nameDAVIS GARVIN AGENCY

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