PAK-LITE, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PAK-LITE, INC. HEALTH AND WELFARE PLAN
401k plan membership statisitcs for PAK-LITE, INC. HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2021: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-09-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 186 |
| Number of retired or separated participants receiving benefits | 2021-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 0 |
| Total of all active and inactive participants | 2021-09-01 | 186 |
| 2020: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 190 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 191 |
| Number of retired or separated participants receiving benefits | 2020-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
| Total of all active and inactive participants | 2020-09-01 | 191 |
| 2019: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-09-01 | 194 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 190 |
| Number of retired or separated participants receiving benefits | 2019-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 0 |
| Total of all active and inactive participants | 2019-09-01 | 190 |
| 2018: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 197 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 193 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 1 |
| Total of all active and inactive participants | 2018-09-01 | 194 |
| 2017: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 172 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 197 |
| Total of all active and inactive participants | 2017-09-01 | 197 |
| 2016: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 147 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 172 |
| Total of all active and inactive participants | 2016-09-01 | 172 |
| 2015: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-09-01 | 131 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 147 |
| Total of all active and inactive participants | 2015-09-01 | 147 |
| 2014: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-09-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 130 |
| Number of retired or separated participants receiving benefits | 2014-09-01 | 1 |
| Total of all active and inactive participants | 2014-09-01 | 131 |
| 2013: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-09-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 125 |
| Total of all active and inactive participants | 2013-09-01 | 125 |
| 2012: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-09-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 125 |
| Total of all active and inactive participants | 2012-09-01 | 125 |
| 2011: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-09-01 | 123 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-09-01 | 120 |
| Number of retired or separated participants receiving benefits | 2011-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-09-01 | 0 |
| Total of all active and inactive participants | 2011-09-01 | 120 |
| 2010: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-09-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-09-01 | 122 |
| Total of all active and inactive participants | 2010-09-01 | 122 |
| 2009: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-09-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 120 |
| Total of all active and inactive participants | 2009-09-01 | 120 |
| 2008: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-09-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-09-01 | 120 |
| Number of retired or separated participants receiving benefits | 2008-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-09-01 | 0 |
| Total of all active and inactive participants | 2008-09-01 | 120 |
| 2021: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-09-01 | Type of plan entity | Single employer plan |
| 2021-09-01 | Submission has been amended | No |
| 2021-09-01 | This submission is the final filing | No |
| 2021-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-09-01 | Plan is a collectively bargained plan | No |
| 2021-09-01 | Plan funding arrangement – Insurance | Yes |
| 2021-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-09-01 | Type of plan entity | Single employer plan |
| 2020-09-01 | Submission has been amended | No |
| 2020-09-01 | This submission is the final filing | No |
| 2020-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-09-01 | Plan is a collectively bargained plan | No |
| 2020-09-01 | Plan funding arrangement – Insurance | Yes |
| 2020-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | Submission has been amended | No |
| 2019-09-01 | This submission is the final filing | No |
| 2019-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-09-01 | Plan is a collectively bargained plan | No |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Submission has been amended | No |
| 2018-09-01 | This submission is the final filing | No |
| 2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-09-01 | Plan is a collectively bargained plan | No |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Submission has been amended | No |
| 2017-09-01 | This submission is the final filing | No |
| 2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-09-01 | Plan is a collectively bargained plan | No |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Submission has been amended | No |
| 2016-09-01 | This submission is the final filing | No |
| 2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-09-01 | Plan is a collectively bargained plan | No |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-09-01 | Type of plan entity | Single employer plan |
| 2015-09-01 | Submission has been amended | No |
| 2015-09-01 | This submission is the final filing | No |
| 2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-09-01 | Plan is a collectively bargained plan | No |
| 2015-09-01 | Plan funding arrangement – Insurance | Yes |
| 2015-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | Submission has been amended | No |
| 2014-09-01 | This submission is the final filing | No |
| 2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-09-01 | Plan is a collectively bargained plan | No |
| 2014-09-01 | Plan funding arrangement – Insurance | Yes |
| 2014-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-09-01 | Type of plan entity | Single employer plan |
| 2013-09-01 | Submission has been amended | No |
| 2013-09-01 | This submission is the final filing | No |
| 2013-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-09-01 | Plan is a collectively bargained plan | No |
| 2013-09-01 | Plan funding arrangement – Insurance | Yes |
| 2013-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-09-01 | Type of plan entity | Single employer plan |
| 2012-09-01 | Submission has been amended | No |
| 2012-09-01 | This submission is the final filing | No |
| 2012-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-09-01 | Plan is a collectively bargained plan | No |
| 2012-09-01 | Plan funding arrangement – Insurance | Yes |
| 2012-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-09-01 | Type of plan entity | Single employer plan |
| 2011-09-01 | Submission has been amended | No |
| 2011-09-01 | This submission is the final filing | No |
| 2011-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-09-01 | Plan is a collectively bargained plan | No |
| 2011-09-01 | Plan funding arrangement – Insurance | Yes |
| 2011-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-09-01 | Type of plan entity | Single employer plan |
| 2010-09-01 | Plan funding arrangement – Insurance | Yes |
| 2010-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-09-01 | Type of plan entity | Single employer plan |
| 2009-09-01 | Plan funding arrangement – Insurance | Yes |
| 2009-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: PAK-LITE, INC. HEALTH AND WELFARE PLAN 2008 form 5500 responses |
|---|
| 2008-09-01 | Type of plan entity | Single employer plan |
| 2008-09-01 | Submission has been amended | Yes |
| 2008-09-01 | This submission is the final filing | No |
| 2008-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-09-01 | Plan is a collectively bargained plan | No |
| 2008-09-01 | Plan funding arrangement – Insurance | Yes |
| 2008-09-01 | Plan benefit arrangement – Insurance | Yes |
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 010765 |
| Policy instance | 2 |
| Insurance contract or identification number | 010765 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $34,453 | | Total amount of fees paid to insurance company | USD $4,162 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SUPPLEMENTAL LIFE; CRITICAL ILLNESS | | 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 $207,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,453 | | Amount paid for insurance broker fees | 4162 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00630339 |
| Policy instance | 1 |
| Insurance contract or identification number | 00630339 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | 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 | Yes | | 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 | | 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 $428,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619648 |
| Policy instance | 2 |
| Insurance contract or identification number | 619648 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | 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 | Yes | | 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 | | 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 $371,300 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMBINED INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | BRKC21992 |
| Policy instance | 1 |
| Insurance contract or identification number | BRKC21992 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $8,861 | | 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 | 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 | ACCIDENT; CRITICAL ILLNESS; HOSPITAL INDEMNITY | | 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 $35,064 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,774 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2692 |
| Policy instance | 3 |
| Insurance contract or identification number | GA2692 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $6,713 | | Total amount of fees paid to insurance company | USD $702 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $95,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,940 | | Amount paid for insurance broker fees | 702 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | GA7765 |
| Policy instance | 4 |
| Insurance contract or identification number | GA7765 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $8,595 | | Total amount of fees paid to insurance company | USD $2,304 | | 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 | 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 $91,974 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,595 | | Amount paid for insurance broker fees | 2304 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | GA7765 |
| Policy instance | 4 |
| Insurance contract or identification number | GA7765 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $1,955 | | Total amount of fees paid to insurance company | USD $575 | | 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 $19,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,295 | | Amount paid for insurance broker fees | 575 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| COMBINED INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | PAKLITE |
| Policy instance | 1 |
| Insurance contract or identification number | PAKLITE | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $5,005 | | 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 | 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 | WORKSITE BENEFITS | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,005 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2692 |
| Policy instance | 3 |
| Insurance contract or identification number | GA2692 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $15,151 | | Total amount of fees paid to insurance company | USD $3,478 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $136,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,140 | | Amount paid for insurance broker fees | 3478 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619648 |
| Policy instance | 2 |
| Insurance contract or identification number | 619648 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $4,526 | | Total amount of fees paid to insurance company | USD $1,429 | | 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 | Yes | | 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 $1,549,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,854 | | Amount paid for insurance broker fees | 1429 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619648 |
| Policy instance | 4 |
| Insurance contract or identification number | 619648 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $884,787 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619648 |
| Policy instance | 2 |
| Insurance contract or identification number | 619648 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $501,216 |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2692 |
| Policy instance | 3 |
| Insurance contract or identification number | GA2692 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $12,887 | | Total amount of fees paid to insurance company | USD $2,373 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $116,373 | | Commission paid to Insurance Broker | USD $1,171 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2373 | | Additional information about fees paid to insurance broker | BONUS |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 530743 |
| Policy instance | 1 |
| Insurance contract or identification number | 530743 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $5,600 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $93,327 | | Commission paid to Insurance Broker | USD $5,600 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | GA7765 |
| Policy instance | 5 |
| Insurance contract or identification number | GA7765 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $2,018 | | Total amount of fees paid to insurance company | USD $122 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,956 | | Commission paid to Insurance Broker | USD $301 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 122 | | Additional information about fees paid to insurance broker | BONUS |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2692 |
| Policy instance | 1 |
| Insurance contract or identification number | GA2692 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $13,555 | | Total amount of fees paid to insurance company | USD $1,177 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $127,035 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619648 |
| Policy instance | 3 |
| Insurance contract or identification number | 619648 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,338,763 |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 530743 |
| Policy instance | 4 |
| Insurance contract or identification number | 530743 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $5,431 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $90,511 |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | GA7765 |
| Policy instance | 2 |
| Insurance contract or identification number | GA7765 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $1,561 | | Total amount of fees paid to insurance company | USD $255 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,025 |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | GA7765 |
| Policy instance | 3 |
| Insurance contract or identification number | GA7765 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $1,234 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $800,440 | | Commission paid to Insurance Broker | USD $1,234 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 530743 |
| Policy instance | 2 |
| Insurance contract or identification number | 530743 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $3,841 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,015 | | Commission paid to Insurance Broker | USD $3,841 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2692 |
| Policy instance | 1 |
| Insurance contract or identification number | GA2692 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $11,396 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $87,779 | | Commission paid to Insurance Broker | USD $11,396 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 530743 |
| Policy instance | 3 |
| Insurance contract or identification number | 530743 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $3,483 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,042 | | Commission paid to Insurance Broker | USD $3,483 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2692 |
| Policy instance | 1 |
| Insurance contract or identification number | GA2692 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $9,835 | | Total amount of fees paid to insurance company | USD $4,672 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,920 | | Commission paid to Insurance Broker | USD $9,835 | | Amount paid for insurance broker fees | 4672 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | GA7765 |
| Policy instance | 2 |
| Insurance contract or identification number | GA7765 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $1,134 | | Total amount of fees paid to insurance company | USD $55 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $790,713 | | Commission paid to Insurance Broker | USD $1,134 | | Amount paid for insurance broker fees | 55 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 224724 |
| Policy instance | 3 |
| Insurance contract or identification number | 224724 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $9,987 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D AND OPTIONAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $66,449 | | Commission paid to Insurance Broker | USD $9,987 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | GA7765 |
| Policy instance | 2 |
| Insurance contract or identification number | GA7765 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $1,037 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $725,532 | | Commission paid to Insurance Broker | USD $1,037 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 530743 |
| Policy instance | 1 |
| Insurance contract or identification number | 530743 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $4,797 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,363 | | Commission paid to Insurance Broker | USD $4,797 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 530743 |
| Policy instance | 4 |
| Insurance contract or identification number | 530743 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $4,746 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,463 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,546 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 224724 |
| Policy instance | 1 |
| Insurance contract or identification number | 224724 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $9,914 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D AND OPTIONAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $66,034 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,509 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | GA7765 |
| Policy instance | 2 |
| Insurance contract or identification number | GA7765 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $6,908 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $687,393 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $232 | | Insurance broker organization code? | 3 | | Insurance broker name | COBBS ALLEN AND HALL INC. |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2291 |
| Policy instance | 3 |
| Insurance contract or identification number | GA2291 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $72 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $-25 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54 | | Insurance broker organization code? | 3 | | Insurance broker name | IVAN M MEASROCH |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2291 |
| Policy instance | 3 |
| Insurance contract or identification number | GA2291 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $879 | | Total amount of fees paid to insurance company | USD $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 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,743 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | 1050681000 |
| Policy instance | 1 |
| Insurance contract or identification number | 1050681000 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $1,959 | | Total amount of fees paid to insurance company | USD $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 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 | Yes | | 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 | | 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 $662 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 460486 |
| Policy instance | 2 |
| Insurance contract or identification number | 460486 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $11,871 | | Total amount of fees paid to insurance company | USD $5,022 | | 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 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $108,086 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00460486 |
| Policy instance | 1 |
| Insurance contract or identification number | 00460486 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $10,659 | | Total amount of fees paid to insurance company | USD $1,739 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $99,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2291 |
| Policy instance | 2 |
| Insurance contract or identification number | GA2291 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $809 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,850 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | G0386 |
| Policy instance | 3 |
| Insurance contract or identification number | G0386 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $15,365 | | Total amount of fees paid to insurance company | USD $3,093 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $429,841 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | G0385 |
| Policy instance | 4 |
| Insurance contract or identification number | G0385 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $5,683 | | Total amount of fees paid to insurance company | USD $1,144 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $162,164 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 714963 |
| Policy instance | 1 |
| Insurance contract or identification number | 714963 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2008-09-01 | | Insurance policy end date | 2009-08-31 | | Total amount of commissions paid to insurance broker | USD $30,094 | | Total amount of fees paid to insurance company | USD $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 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 | Yes | | 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 $585,834 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,094 | | Insurance broker organization code? | 3 | | Insurance broker name | THE MCCART GROUP, INC. |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 00165 |
| Policy instance | 2 |
| Insurance contract or identification number | 00165 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2008-09-01 | | Insurance policy end date | 2009-08-31 | | Total amount of commissions paid to insurance broker | USD $10,988 | | Total amount of fees paid to insurance company | USD $43 | | 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 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | OPTIONAL AND ACCIDENTAL LIFE PLANS | | 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 $146,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,988 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 43 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | AXA ASSISTANCE USA |
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