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GLOCK, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan NameGLOCK, INC. WELFARE BENEFIT PLAN
Plan identification number 501

GLOCK, INC. WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

GLOCK, INC. has sponsored the creation of one or more 401k plans.

Company Name:GLOCK, INC.
Employer identification number (EIN):581652822
NAIC Classification:339900

Additional information about GLOCK, INC.

Jurisdiction of Incorporation: Georgia Department of States Corporations Division
Incorporation Date: 1985-11-27
Company Identification Number: 692860
Legal Registered Office Address: 6000 HIGHLANDS PKWY SE

SMYRNA
United States of America (USA)
30082-7204

More information about GLOCK, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GLOCK, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01
5012017-01-01.
5012016-01-01CARLOS GUEVARA
5012015-01-01CARLOS GUEVARA
5012014-01-01CARLOS GUEVARA
5012013-01-01CARLOS GUEVARA
5012012-01-01CARLOS GUEVARA
5012011-01-01CHAD MATHIS
5012010-01-01GARY FLETCHER
5012009-01-01GARY FLETCHER

Plan Statistics for GLOCK, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for GLOCK, INC. WELFARE BENEFIT PLAN

Measure Date Value
2022: GLOCK, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01670
Total number of active participants reported on line 7a of the Form 55002022-01-01641
Number of retired or separated participants receiving benefits2022-01-015
Number of other retired or separated participants entitled to future benefits2022-01-01130
Total of all active and inactive participants2022-01-01776
2021: GLOCK, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01582
Total number of active participants reported on line 7a of the Form 55002021-01-01603
Number of retired or separated participants receiving benefits2021-01-015
Number of other retired or separated participants entitled to future benefits2021-01-01124
Total of all active and inactive participants2021-01-01732
2020: GLOCK, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01538
Total number of active participants reported on line 7a of the Form 55002020-01-01578
Number of retired or separated participants receiving benefits2020-01-0179
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01657
2019: GLOCK, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01484
Total number of active participants reported on line 7a of the Form 55002019-01-01516
Number of retired or separated participants receiving benefits2019-01-014
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01520
2018: GLOCK, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01497
Total number of active participants reported on line 7a of the Form 55002018-01-01528
Number of retired or separated participants receiving benefits2018-01-011
Number of other retired or separated participants entitled to future benefits2018-01-011
Total of all active and inactive participants2018-01-01530
2017: GLOCK, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01445
Total number of active participants reported on line 7a of the Form 55002017-01-01497
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01497
2016: GLOCK, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01420
Total number of active participants reported on line 7a of the Form 55002016-01-01443
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-012
Total of all active and inactive participants2016-01-01445
2015: GLOCK, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01451
Total number of active participants reported on line 7a of the Form 55002015-01-01392
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-0128
Total of all active and inactive participants2015-01-01420
2014: GLOCK, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01415
Total number of active participants reported on line 7a of the Form 55002014-01-01388
Number of retired or separated participants receiving benefits2014-01-0159
Number of other retired or separated participants entitled to future benefits2014-01-014
Total of all active and inactive participants2014-01-01451
2013: GLOCK, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01289
Total number of active participants reported on line 7a of the Form 55002013-01-01415
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 participants2013-01-01415
2012: GLOCK, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01220
Total number of active participants reported on line 7a of the Form 55002012-01-01289
Number of retired or separated participants receiving benefits2012-01-010
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01289
2011: GLOCK, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01189
Total number of active participants reported on line 7a of the Form 55002011-01-01220
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01220
2010: GLOCK, INC. WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01172
Total number of active participants reported on line 7a of the Form 55002010-01-01188
Number of retired or separated participants receiving benefits2010-01-011
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-01189
2009: GLOCK, INC. WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01166
Total number of active participants reported on line 7a of the Form 55002009-01-01172
Total of all active and inactive participants2009-01-01172

Form 5500 Responses for GLOCK, INC. WELFARE BENEFIT PLAN

2022: GLOCK, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: GLOCK, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
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: GLOCK, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
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: GLOCK, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
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: GLOCK, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
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: GLOCK, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
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: GLOCK, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
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: GLOCK, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
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: GLOCK, INC. WELFARE BENEFIT 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: GLOCK, INC. WELFARE BENEFIT 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: GLOCK, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
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: GLOCK, INC. WELFARE BENEFIT 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: GLOCK, INC. WELFARE BENEFIT 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: GLOCK, INC. WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01This submission is the final filingNo
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

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 6
Insurance contract or identification number24813
Number of Individuals Covered315
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $2,164
Total amount of fees paid to insurance companyUSD $167
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,164
Amount paid for insurance broker fees0
Insurance broker organization code?5
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered1501
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $2,411
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $70,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,411
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 2
Insurance contract or identification numberGA6550
Number of Individuals Covered1212
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $349,083
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,203,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $349,083
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 3
Insurance contract or identification number24813
Number of Individuals Covered1325
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $23,211
Total amount of fees paid to insurance companyUSD $1,792
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $154,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,211
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 4
Insurance contract or identification number24813
Number of Individuals Covered747
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $15,575
Total amount of fees paid to insurance companyUSD $1,202
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $103,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,575
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 5
Insurance contract or identification number24813
Number of Individuals Covered1375
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $1,149
Total amount of fees paid to insurance companyUSD $89
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $7,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,149
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05947364
Policy instance 14
Insurance contract or identification numberTM05947364
Number of Individuals Covered1524
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $17,892
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $522,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,892
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 7
Insurance contract or identification number24813
Number of Individuals Covered310
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $341
Total amount of fees paid to insurance companyUSD $27
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $341
Amount paid for insurance broker fees0
Insurance broker organization code?1
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 8
Insurance contract or identification number24813
Number of Individuals Covered1327
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $7,512
Total amount of fees paid to insurance companyUSD $580
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $50,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,512
Amount paid for insurance broker fees0
Insurance broker organization code?1
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 9
Insurance contract or identification number24813
Number of Individuals Covered1327
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $1,002
Total amount of fees paid to insurance companyUSD $78
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,002
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 10
Insurance contract or identification number24813
Number of Individuals Covered1325
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $17,171
Total amount of fees paid to insurance companyUSD $1,325
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $114,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,171
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 11
Insurance contract or identification number24813
Number of Individuals Covered1
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $6
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedNEW YORK DBL
Welfare Benefit Premiums Paid to CarrierUSD $40
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 12
Insurance contract or identification numberGA6550
Number of Individuals Covered790
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $80,392
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,349,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $80,392
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 13
Insurance contract or identification number24813
Number of Individuals Covered1
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $70
Total amount of fees paid to insurance companyUSD $5
Other welfare benefits providedNEW YORK PAID FAMILY LEAVE
Welfare Benefit Premiums Paid to CarrierUSD $465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $70
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 3
Insurance contract or identification number24813
Number of Individuals Covered1207
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $22,379
Total amount of fees paid to insurance companyUSD $1,546
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $131,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,379
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 2
Insurance contract or identification numberGA6550
Number of Individuals Covered1187
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $310,943
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,569,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $310,943
Amount paid for insurance broker fees0
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 numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered1455
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $2,117
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $65,140
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,117
Amount paid for insurance broker fees0
Insurance broker organization code?3
FLORES AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )
Policy contract number
Policy instance 15
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees729
Insurance broker organization code?5
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05947364
Policy instance 14
Insurance contract or identification numberTM05947364
Number of Individuals Covered1478
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $15,661
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $481,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,661
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 13
Insurance contract or identification number24813
Number of Individuals Covered4
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $126
Total amount of fees paid to insurance companyUSD $8
Other welfare benefits providedNEW YORK PAID FAMILY LEAVE
Welfare Benefit Premiums Paid to CarrierUSD $741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $126
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 4
Insurance contract or identification number24813
Number of Individuals Covered722
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $16,262
Total amount of fees paid to insurance companyUSD $1,124
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $95,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,262
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 5
Insurance contract or identification number24813
Number of Individuals Covered1376
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $1,193
Total amount of fees paid to insurance companyUSD $82
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $7,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,193
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 12
Insurance contract or identification numberGA6550
Number of Individuals Covered273
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $68,567
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,110,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $68,567
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 11
Insurance contract or identification number24813
Number of Individuals Covered3
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $11
Total amount of fees paid to insurance companyUSD $1
Other welfare benefits providedNEW YORK DBL
Welfare Benefit Premiums Paid to CarrierUSD $63
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 10
Insurance contract or identification number24813
Number of Individuals Covered1208
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $16,574
Total amount of fees paid to insurance companyUSD $1,145
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $97,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,574
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 9
Insurance contract or identification number24813
Number of Individuals Covered1207
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $979
Total amount of fees paid to insurance companyUSD $68
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $5,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $979
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 8
Insurance contract or identification number24813
Number of Individuals Covered1207
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $7,343
Total amount of fees paid to insurance companyUSD $507
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $43,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,343
Amount paid for insurance broker fees0
Insurance broker organization code?1
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 7
Insurance contract or identification number24813
Number of Individuals Covered327
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $308
Total amount of fees paid to insurance companyUSD $22
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $308
Amount paid for insurance broker fees0
Insurance broker organization code?1
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 6
Insurance contract or identification number24813
Number of Individuals Covered324
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $2,472
Total amount of fees paid to insurance companyUSD $171
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,472
Amount paid for insurance broker fees0
Insurance broker organization code?5
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 6
Insurance contract or identification number24813
Number of Individuals Covered146
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $2,129
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,129
Amount paid for insurance broker fees0
Insurance broker organization code?5
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 5
Insurance contract or identification number24813
Number of Individuals Covered644
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $1,079
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,079
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 4
Insurance contract or identification number24813
Number of Individuals Covered341
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $14,820
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $87,113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,820
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 3
Insurance contract or identification number24813
Number of Individuals Covered535
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $20,374
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $119,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,374
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 2
Insurance contract or identification numberGA6550
Number of Individuals Covered992
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $257,352
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,755,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $257,352
Amount paid for insurance broker fees0
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 numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered1247
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $1,923
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,923
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 7
Insurance contract or identification number24813
Number of Individuals Covered158
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $308
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $308
Amount paid for insurance broker fees0
Insurance broker organization code?1
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 8
Insurance contract or identification number24813
Number of Individuals Covered536
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $6,602
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $38,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,602
Amount paid for insurance broker fees0
Insurance broker organization code?1
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05947364
Policy instance 14
Insurance contract or identification numberTM05947364
Number of Individuals Covered1277
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $15,041
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $453,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,041
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 13
Insurance contract or identification number24813
Number of Individuals Covered2
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $60
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedNEW YORK PAID FAMILY LEAVE
Welfare Benefit Premiums Paid to CarrierUSD $350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $60
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 12
Insurance contract or identification numberGA6550
Number of Individuals Covered254
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $59,941
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,806,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59,941
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 11
Insurance contract or identification number24813
Number of Individuals Covered1
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $6
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedNEW YORK DBL
Welfare Benefit Premiums Paid to CarrierUSD $36
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 10
Insurance contract or identification number24813
Number of Individuals Covered535
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $13,199
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $77,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,199
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 9
Insurance contract or identification number24813
Number of Individuals Covered536
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $880
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $5,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $880
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 7
Insurance contract or identification number24813
Number of Individuals Covered166
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $275
Total amount of fees paid to insurance companyUSD $23
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $275
Amount paid for insurance broker fees0
Insurance broker organization code?1
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 8
Insurance contract or identification number24813
Number of Individuals Covered537
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $5,923
Total amount of fees paid to insurance companyUSD $506
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $39,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,923
Amount paid for insurance broker fees0
Insurance broker organization code?1
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 9
Insurance contract or identification number24813
Number of Individuals Covered537
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $785
Total amount of fees paid to insurance companyUSD $67
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $5,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $785
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 10
Insurance contract or identification number24813
Number of Individuals Covered537
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $11,632
Total amount of fees paid to insurance companyUSD $994
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $77,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,632
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 11
Insurance contract or identification number24813
Number of Individuals Covered2
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $10
Total amount of fees paid to insurance companyUSD $1
Other welfare benefits providedNEW YORK DBL
Welfare Benefit Premiums Paid to CarrierUSD $66
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 12
Insurance contract or identification numberGA6550
Number of Individuals Covered240
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $54,570
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,592,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54,570
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05947364
Policy instance 14
Insurance contract or identification numberTM05947364
Number of Individuals Covered1200
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $19,115
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $382,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,115
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 6
Insurance contract or identification number24813
Number of Individuals Covered147
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $1,845
Total amount of fees paid to insurance companyUSD $158
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,845
Amount paid for insurance broker fees0
Insurance broker organization code?5
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 5
Insurance contract or identification number24813
Number of Individuals Covered662
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $1,010
Total amount of fees paid to insurance companyUSD $86
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,010
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 4
Insurance contract or identification number24813
Number of Individuals Covered350
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $12,914
Total amount of fees paid to insurance companyUSD $1,103
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $86,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,914
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 3
Insurance contract or identification number24813
Number of Individuals Covered537
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $17,840
Total amount of fees paid to insurance companyUSD $1,524
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $119,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,840
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 2
Insurance contract or identification numberGA6550
Number of Individuals Covered982
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $260,593
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,604,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $260,593
Amount paid for insurance broker fees0
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 numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered1226
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $1,995
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,995
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 13
Insurance contract or identification number24813
Number of Individuals Covered2
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $32
Total amount of fees paid to insurance companyUSD $3
Other welfare benefits providedNEW YORK PAID FAMILY LEAVE
Welfare Benefit Premiums Paid to CarrierUSD $211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 7
Insurance contract or identification number24813
Number of Individuals Covered155
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $254
Total amount of fees paid to insurance companyUSD $26
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $254
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 8
Insurance contract or identification number24813
Number of Individuals Covered546
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $5,169
Total amount of fees paid to insurance companyUSD $532
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,169
Amount paid for insurance broker fees0
Insurance broker organization code?0
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 9
Insurance contract or identification number24813
Number of Individuals Covered546
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $689
Total amount of fees paid to insurance companyUSD $71
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $689
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05947364
Policy instance 14
Insurance contract or identification numberTM05947364
Number of Individuals Covered1221
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $16,334
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $357,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,334
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 10
Insurance contract or identification number24813
Number of Individuals Covered545
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $9,018
Total amount of fees paid to insurance companyUSD $928
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $60,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,018
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 12
Insurance contract or identification numberGA6550
Number of Individuals Covered220
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $53,608
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,580,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,608
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 11
Insurance contract or identification number24813
Number of Individuals Covered2
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $11
Total amount of fees paid to insurance companyUSD $1
Other welfare benefits providedNEW YORK DBL
Welfare Benefit Premiums Paid to CarrierUSD $72
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 6
Insurance contract or identification number24813
Number of Individuals Covered142
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $1,851
Total amount of fees paid to insurance companyUSD $190
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,851
Amount paid for insurance broker fees0
Insurance broker organization code?1
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 5
Insurance contract or identification number24813
Number of Individuals Covered637
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $924
Total amount of fees paid to insurance companyUSD $96
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $924
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 4
Insurance contract or identification number24813
Number of Individuals Covered340
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $11,541
Total amount of fees paid to insurance companyUSD $1,188
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $76,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,541
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 3
Insurance contract or identification number24813
Number of Individuals Covered545
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $11,274
Total amount of fees paid to insurance companyUSD $1,160
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $75,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,274
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 2
Insurance contract or identification numberGA6550
Number of Individuals Covered1029
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $246,670
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,274,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $246,670
Amount paid for insurance broker fees0
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 numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered1262
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $1,904
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $56,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,904
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 13
Insurance contract or identification number24813
Number of Individuals Covered2
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $23
Total amount of fees paid to insurance companyUSD $2
Other welfare benefits providedNEW YORK PAID FAMILY LEAVE
Welfare Benefit Premiums Paid to CarrierUSD $151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 6
Insurance contract or identification number24813
Number of Individuals Covered332
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $10,617
Total amount of fees paid to insurance companyUSD $1,113
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $70,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,617
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 5
Insurance contract or identification number24813
Number of Individuals Covered510
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $11,248
Total amount of fees paid to insurance companyUSD $1,179
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $74,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,248
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number955038
Policy instance 4
Insurance contract or identification number955038
Number of Individuals Covered497
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $16,912
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $338,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,912
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 3
Insurance contract or identification numberGA6550
Number of Individuals Covered948
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $240,277
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,559,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $240,277
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA6550
Policy instance 2
Insurance contract or identification numberGA6550
Number of Individuals Covered1187
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $2,043
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $55,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,043
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered0
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $0
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 $0
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 7
Insurance contract or identification number24813
Number of Individuals Covered627
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $891
Total amount of fees paid to insurance companyUSD $94
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $5,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $891
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 8
Insurance contract or identification number24813
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $1,735
Total amount of fees paid to insurance companyUSD $181
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,735
Amount paid for insurance broker fees0
Insurance broker organization code?1
Insurance broker nameAXA ASSISTANCE, USA
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 14
Insurance contract or identification numberGA6550
Number of Individuals Covered233
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $59,904
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,635,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59,904
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 12
Insurance contract or identification number24813
Number of Individuals Covered510
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $9,001
Total amount of fees paid to insurance companyUSD $944
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $60,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,001
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 13
Insurance contract or identification number24813
Number of Individuals Covered2
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $11
Total amount of fees paid to insurance companyUSD $1
Other welfare benefits providedNEW YORK DBL
Welfare Benefit Premiums Paid to CarrierUSD $72
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 11
Insurance contract or identification number24813
Number of Individuals Covered512
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $686
Total amount of fees paid to insurance companyUSD $72
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $686
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 10
Insurance contract or identification number24813
Number of Individuals Covered512
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $5,143
Total amount of fees paid to insurance companyUSD $539
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,143
Amount paid for insurance broker fees0
Insurance broker organization code?0
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 9
Insurance contract or identification number24813
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $248
Total amount of fees paid to insurance companyUSD $26
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $248
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 9
Insurance contract or identification number24813
Number of Individuals Covered0
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $215
Total amount of fees paid to insurance companyUSD $20
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $215
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 8
Insurance contract or identification number24813
Number of Individuals Covered0
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $1,749
Total amount of fees paid to insurance companyUSD $161
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,749
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 7
Insurance contract or identification number24813
Number of Individuals Covered498
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $787
Total amount of fees paid to insurance companyUSD $72
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $787
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 5
Insurance contract or identification number24813
Number of Individuals Covered389
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $9,360
Total amount of fees paid to insurance companyUSD $860
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $54,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,360
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number955038
Policy instance 4
Insurance contract or identification number955038
Number of Individuals Covered387
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $12,006
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $240,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,006
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 3
Insurance contract or identification numberGA6550
Number of Individuals Covered726
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $180,594
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,761,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $180,594
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA6550
Policy instance 2
Insurance contract or identification numberGA6550
Number of Individuals Covered916
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $2,185
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,185
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered184
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $57,592
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,199,603
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $57,592
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 10
Insurance contract or identification number24813
Number of Individuals Covered389
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $4,304
Total amount of fees paid to insurance companyUSD $395
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,304
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 11
Insurance contract or identification number24813
Number of Individuals Covered389
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $574
Total amount of fees paid to insurance companyUSD $52
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $574
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 12
Insurance contract or identification number24813
Number of Individuals Covered389
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $6,694
Total amount of fees paid to insurance companyUSD $615
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $39,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,694
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 13
Insurance contract or identification number24813
Number of Individuals Covered2
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $12
Total amount of fees paid to insurance companyUSD $1
Other welfare benefits providedNEW YORK DBL
Welfare Benefit Premiums Paid to CarrierUSD $72
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameCOMPSYCH
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number24813
Policy instance 6
Insurance contract or identification number24813
Number of Individuals Covered263
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $8,509
Total amount of fees paid to insurance companyUSD $781
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $49,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,509
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010182062
Policy instance 5
Insurance contract or identification number000010182062
Number of Individuals Covered396
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $8,699
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $48,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,699
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010182061
Policy instance 4
Insurance contract or identification number000010182061
Number of Individuals Covered396
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $5,170
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $28,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,170
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 3
Insurance contract or identification numberGA6550
Number of Individuals Covered713
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $163,090
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,336,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $163,090
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA6550
Policy instance 2
Insurance contract or identification numberGA6550
Number of Individuals Covered865
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $2,262
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $46,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,262
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered190
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $54,468
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,114,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54,468
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010182063
Policy instance 6
Insurance contract or identification number000010182063
Number of Individuals Covered396
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $4,759
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,759
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000400001000
Policy instance 8
Insurance contract or identification number000400001000
Number of Individuals Covered364
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $6,996
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $38,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,996
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000403002701
Policy instance 7
Insurance contract or identification number000403002701
Number of Individuals Covered361
Insurance policy start date2013-11-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $618
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $618
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA6550
Policy instance 1
Insurance contract or identification numberGA6550
Number of Individuals Covered183
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $68,716
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $732,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $68,716
Insurance broker organization code?3
Insurance broker nameHAVEN BENEFITS
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05588676
Policy instance 2
Insurance contract or identification numberTM05588676
Number of Individuals Covered803
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $28,683
Total amount of fees paid to insurance companyUSD $589
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $330,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,124
Insurance broker organization code?3
Amount paid for insurance broker fees589
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker nameMCGRIFF SEIBELS & WILLIAMS
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6550
Policy instance 3
Insurance contract or identification numberGA6550
Number of Individuals Covered627
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $72,149
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,646,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $72,149
Insurance broker organization code?3
Insurance broker nameMCGRIFF SEIBELS & WILLIAMS
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA20120001
Policy instance 1
Insurance contract or identification numberGA20120001
Number of Individuals Covered158
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $107,479
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $641,322
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $107,479
Insurance broker organization code?3
Insurance broker nameMCGRIFF SEIBELS & WILLIAMS
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05588676
Policy instance 2
Insurance contract or identification numberTM05588676
Number of Individuals Covered600
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $23,849
Total amount of fees paid to insurance companyUSD $13
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $266,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,849
Amount paid for insurance broker fees13
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameMCGRIFF SEIBELS & WILLIAMS
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA20120001
Policy instance 3
Insurance contract or identification numberGA20120001
Number of Individuals Covered448
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $8,514
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,728,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,514
Insurance broker organization code?3
Insurance broker nameMCGRIFF SEIBELS & WILLIAMS
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA20120001
Policy instance 3
Insurance contract or identification numberGA20120001
Number of Individuals Covered369
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $66,036
Total amount of fees paid to insurance companyUSD $328
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,332,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05588676
Policy instance 2
Insurance contract or identification numberTM05588676
Number of Individuals Covered498
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $22,129
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD & D
Welfare Benefit Premiums Paid to CarrierUSD $234,846
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 numberGA20120001
Policy instance 1
Insurance contract or identification numberGA20120001
Number of Individuals Covered122
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $28,250
Total amount of fees paid to insurance companyUSD $140
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $569,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05588676
Policy instance 2
Insurance contract or identification numberTM05588676
Number of Individuals Covered466
Insurance policy start date2009-11-01
Insurance policy end date2010-10-31
Total amount of commissions paid to insurance brokerUSD $17,148
Total amount of fees paid to insurance companyUSD $950
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD & D
Welfare Benefit Premiums Paid to CarrierUSD $196,429
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 numberGA20120001
Policy instance 3
Insurance contract or identification numberGA20120001
Number of Individuals Covered310
Insurance policy start date2009-11-01
Insurance policy end date2010-10-31
Total amount of commissions paid to insurance brokerUSD $85,814
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,205,141
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 numberGA20120001
Policy instance 1
Insurance contract or identification numberGA20120001
Number of Individuals Covered121
Insurance policy start date2009-11-01
Insurance policy end date2010-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $542,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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